The Danish psychologist Edgar Rubin is perhaps best known for developing the optical illusion known as the Rubin vase, shown in the picture to the right. Is it a picture of a black vase, or is it a picture of the white profiles of two people looking at each other? Looking at the picture, one sees either the vase or the two people (although with time and practice one can see both). The picture demonstrates how the same picture can be viewed in different ways, depending on who is looking at it.
Video reflexive ethnography (VRE) is both a method and an intervention and part of the power of VRE comes in its ability to reveal something that previously was hidden from view, similar to the experience one has when looking at the Rubin vase for the first time. For example, one may see only a vase, and the profiles of two people facing each other are hidden from view until the profiles are brought to our attention. In healthcare the same phenomenon occurs, with video playing the role of revealing our actions because video captures both language and non-verbal behaviors. Clinicians across a variety of healthcare settings engage in many, many activities and tasks throughout the day (and night). During any single activity our minds are often occupied by other matters: what is next on the “to do” list or where to find a quick bite of food when the activity has been completed, for example. Even when the activity is video-recorded, although we may initially be very aware of the camera filming our actions, eventually our concentration will drift away from the camera because our minds either focus on the activity at hand or become occupied by other matters. We are unaware of the effect of the video-recording process on what we were doing until we review a video of the activity. When reviewing the video, actions that were hidden become revealed: we may see something that we don’t remember doing or saying, or we may see something that in the moment seemed peripheral to the main activity but in the video seems suddenly very important. Why is that?
Anaïs Nin once said, “We don’t see things as they are. We see things as we are.” Our subjective human natures cannot overcome recall and other biases without help, and this is why video reflexive ethnography can be such a powerful tool. Let’s look at inserting an intravenous line as an example of a clinical activity that may benefit from a video reflexive ethnography lens. Venous catheters are a significant source of infection and the insertion process may contribute to infection risk. Physicians and advanced practice providers insert central venous catheters while nurses usually insert peripheral intravenous catheters. When learning how to insert a venous catheter, our minds are quite focused on the task at hand but with experience and repetition the insertion process takes less conscious effort and the activity becomes a habit. Once we develop a habit, it no longer sits in conscious memory but becomes part of our sub-conscious selves. Without the conscious awareness that characterized learning how to insert a catheter, we may be poor judges of our performance and any risk of infection arising from our performance. However, video reflexive ethnography reveals patterns of behavior that may be missed in real time. Independent video review provides an unvarnished record of the activity, allowing us to develop insights into behaviors that are habitual and thus behaviors that are often habitual and thus enacted without conscious awareness. The ethnographic portion of the method reveals contextual features that were present and either contributed to success or challenges in completing the activity. Reflexivity sessions (discussed in last month’s blog) bring in the opinions of our peers to help interpret and learn from the videos.
In summary, video reflexive ethnography helps us “see” things in a new light, in much the same way as Rubin’s vase. Patients across healthcare settings continue to experience preventable harms such as hospital-acquired infections, physical injury and disability, unplanned hospital readmissions, longer lengths of stay, and death. Despite these ongoing gaps in keeping patients safe, every day in every healthcare organization clinicians find ways to save lives but their safety practices are often invisible to others and sometimes even to themselves. Thus, adapting video reflexive ethnography can refresh and reinvigorate the discussion into how patients can be kept free from harm.