Sparking Change: Frictions as a Key Function of Ethnography for Healthcare Improvement

Abstract

Anthropologists increasingly engage with healthcare systems, using ethnographic research as a critical tool for understanding and improving healthcare practices. The resulting interactions and collaborations between ethnographers, healthcare practitioners, and administrators often give rise to ‘frictions’—moments of tension, frustrations, misalignments, and misunderstandings. In physics, friction is the force that one object’s surface exerts over another’s to slow its motion, push back against its inherent energy and movement, and is a constant at all touchpoints between the objects, from both sides. While friction often evokes negative connotations, in this article, we look beyond frictions as obstacles, and instead explore them as productive forces that can drive transformation in the healthcare improvement field. Drawing both on the authors’ own experiences and on the work of other anthropologists, we reflect on how friction helps shed light on the dynamics of interdisciplinary work and improve collaboration. We unpack how conceptual and ethical frictions in applied ethnographic work reveal deeper structural and relational insights that would otherwise remain obscured. This article contributes to anthropological discussions on interdisciplinary collaboration and applied practice, and it offers concrete strategies for handling different kinds of friction in health-related ethnographic research.

“[T]he propensity of critical ethnography [is] to ‘unsettle’. But the uneasiness it provokes is not an obstacle to knowledge or action: it is their condition”.

(Fassin, 2013, p. 125).

1. Introduction

Ethnography as a methodology has its roots in the anthropological tradition. It developed both methodologically and epistemologically out of the global paradigm shifts of the late 19th century, as a push-back to the positivist ‘armchair anthropologist’ model of understanding people from other cultures from afar. Ethnography was later adopted beyond anthropology in akin disciplines such as sociology as a model for exploring the social worlds of everyday life in modern Western society (Deegan, 2001). Central to the approach in both disciplines was a commitment to challenging ethnocentrism and social normativity, and problematizing westernized and politically classed understandings about practice (Scott-Jones, 2010).

Within the healthcare improvement community of practice, ethnography was established in the early 2000s as a method for observing the context in which healthcare issues and interventions occur, and how contextual factors shape action and outcomes (Leslie et al., 2013; Hackett & Hayre, 2020). From these beginnings, ethnography has turned into a powerful force and a well-recognized method of insight-generation and evaluation within health research and the healthcare improvement space.

While rooted in the history of anthropology as a discipline, the problematizing of westernized and politically classed understandings is a perspective and an approach that cannot be assumed to be shared, understood, and agreed upon by researchers and practitioners from other disciplines, including those in medicine and healthcare. The fundamental orientation of ethnography can be quite jarring for researchers who may not have considered that issues of healthcare service improvement and patient outcomes may be linked to core assumptions embedded in western healthcare and bio-medical practices, and/or who do not share the value or prioritization of this approach to improving healthcare services, and patient or community outcomes. Thus, the work of ethnography for healthcare improvement inherently involves frictions as a component of the collaborative work between anthropologists and healthcare practitioners and administrators to improve healthcare services and ultimately patient outcomes.

In this manuscript, we reflect on these frictions as an important means of moving the healthcare improvement field forward. Per physics, friction is the force that an object’s surface exerts over another’s to slow its motion, push against its inherent energy and movement, and occurs as a constant at each touchpoint between the objects (Marion, 1981). In this article, we use friction to refer to the tensions, frustrations, misalignments, and misunderstandings that ethnographers experience in collaborative relationships with our research partners in healthcare settings. These frictions stem from different expectations, interpretations, and logics amongst ethnographers and collaborators, linked to disciplinary approaches and how these spaces and differences are navigated. While commonly evoking a negative connotation, friction also has positive results that are the focus of the present article. By reflecting on frictions, we zoom in on instances when things are not in alignment to understand what the tension adds to our research.

Much of the literature about healthcare ethnography laments the difficulties we face as ethnographers in making our perspective understood and valued in healthcare settings. Previously, Anspach and Mizrachi (2006) and Hughes (2019) have written about the “tensions” of conducting ethnographic fieldwork in healthcare spaces from the standpoints of sociological and anthropological researchers, respectively. They comment on the ethical quandaries that arise in the ethnographer’s situation between the academic disciplinary “field” and the clinical “fields” and spaces of the ethnographic research, and the inevitable reality that ethnographers will “antagonize those we study” (Anspach & Mizrachi, 2006, p. 716) due to these differences. They also comment on struggles to “make [ethnographic] knowledge matter in the world of evaluations and decision-making” which make it “impossible to reconcile very different understandings of the world” (Hughes, 2019, pp. 41, 45). In both cases, the authors take on a position that epistemological differences between ethnographers and the clinical world create frictions between the two parties, failing to see the ethnographer’s potential and putting them in a position of intellectual crisis and conflict.

In the present paper, we add our own critical reflections as anthropologists to this area of methodological thought, drawing collectively on our diverse experience, and present a further perspective that sees benefits as an outcome of friction, and we further develop this scientific analogy. In physics, frictional forces may be beneficial: friction grips our shoes to the ground when we walk, and creates the spark when a match is lit. In this same way, we borrow from the business concept of ‘productive friction’ (Hagel & Brown, 2005) to critically consider how some of the frictions that are inherent within the philosophies and processes of ethnographic work in healthcare may become spaces of creation, innovation and improvement. We see frictions as a ‘necessary evil’ and as a condition for impactful healthcare improvement in terms of how they are held, surfaced, and managed.

2. Background

In 2019, the Social Science, Applied Healthcare and Improvement Research (SAPPHIRE) group at the University of Leicester, UK, held its first annual Ethnography for Healthcare Improvement summer school, inviting ethnographers from across the world to learn, share, network, and reflect on conducting ethnographic work in healthcare settings as part of healthcare improvement efforts and agendas. During the 2022 edition of the summer school, we (the authors) were among the anthropologists in attendance, and shared some of the challenges we faced in conducting ethnographies in healthcare settings. This included challenges such as navigating the difficulties among our clinical partners of relating to ethnographic research that does not formulate or test a hypothesis, is not measurable, is not replicable or easily transferable, and may seem too small-scale, not ‘objective’, and/or beset by bias. In our discussion, we began to flesh out some root causes of these frictions. These included, broadly, the different purposes, subjects, methods, logics and ultimate goals of research between ethnographers compared to many partners in healthcare settings, including providers, nurses, administrators, and leadership in health systems that commission and/or fund healthcare research. This discussion was the start of an ongoing conversation among us about these challenges, the roots of these tensions, and strategies for effectively recognizing, responding to, and negotiating with them. These negotiations sometimes lead to improved communication and richer research questions, while other times they uncover core differences that lead us either to compromise or to step back and reconsider the value/benefit of the research partnership at a more fundamental level.

This paper provides a new perspective, drawn from the authors’ insights across different countries and 30 years of combined experience as ethnographers in healthcare improvement. The purpose of this article is to describe and discuss examples of frictions experienced in healthcare research between ethnographers and their medical and healthcare collaborators, and to offer recommendations for navigating this landscape. We organize our thinking around two main types of friction—conceptual and ethical—and illustrate these frictions with examples drawn from the literature and/or the experiences of the authors. We conclude with a discussion of the implications of these frictions, and practical strategies for addressing and, when possible, resolving them. Finally, we offer reflections on the broader implications for ethnography in healthcare settings.

3. Conceptual Frictions

Ethnographers collaborate with stakeholders from other traditions and mindsets—not only other research methodologists, but also clinical and non-clinical practitioners, healthcare managers, and research funders, to name a few. These stakeholders come with very different ontological and epistemological stances compared to the ethnographer, shaping the different ways we see the world, understand sources of knowledge, and our investigative approaches. As a result, frictions can arise in the conceptual stage of designing research including when formulating research questions and selecting methodological approaches. These frictions are better explained by drawing on an example.

Example: Anna’s story:

When one of the authors (whom we here choose to call Anna) began a research collaboration with a teaching hospital, the invitation came framed as follows: “Our culture is not safe. As anthropologists are experts on culture, can you help us measure how safe our culture is on some of our wards?” In posing this question, hospital professionals were concerned that everyday work practices fell short of the normative ideal: a culture in which healthcare staff feel able to ask for help, express uncertainties, and report errors without fear of stigma (Frazier et al., 2017). It was clarified early in the collaboration that culture cannot be precisely measured and that ethnography could nonetheless provide rich insights into the dynamics of daily work. This early friction led to a reframing of the research question from “Can you measure how safe our culture is?” to “How do healthcare professionals experience (un)safety in their daily work?” This reformulation became an ongoing source of friction as it required multiple new conversations about what kinds of ‘evidence’ and ‘results’ could be expected from ethnographic observations, even as shadowing sessions with staff began. Observations soon revealed that doors played a significant role as physical as well as figurative barriers, creating a sense of separation and raising the threshold for communication between different professional groups. This insight was shared during the regular feedback sessions with staff on the ward arranged during the ethnographic fieldwork. Because most interactions across groups occurred mainly in formal contexts such as grand rounds and hand-offs, these sessions inadvertently inspired the introduction of informal opportunities for interaction. These new moments of contact opened doors (both physically and figuratively) that would otherwise have remained closed and contributed to a more relaxed atmosphere, softening some of the barriers that had previously limited communication.

Similar instances in which the research questions were revised come from the literature. In a collaborative research project on information within the doctor–patient relationship, Fainzang (2010) illustrates how friction early in the research process led to negotiating which research questions should be asked and the corresponding research design. Following the introduction of a new law in France that guarantees people access to all medical information pertaining to them, Fainzang was asked to research the difficulties doctors faced in sharing this information with patients. Doctors themselves largely attributed these difficulties to technical reasons (having to explain conditions in ways that were accessible to patients) or psychological reasons (patients’ denial as they struggle to cope with news about illness). Based on these hypotheses, doctors suggested a questionnaire-based study among patients to ascertain whether and how to communicate the truth about a patient’s health in ways that are non-traumatic and that ensure that patients understand their condition, provide informed consent, and adhere to treatment. As an anthropologist and trained ethnographer, Fainzang, however, had different questions and research design than those envisaged by doctors and proposed to first inductively examine the reality of patient information by means of a double ethnographic study involving both patients and doctors. Fainzang insisted that questions needed to be formulated differently for the research to unpack the social mechanisms underlying doctor–patient information exchange and to investigate “the cognitive and moral systems in which their stances were anchored […] to see how the use, search for, disclosure or retention of information is put into effect” (Fainzang, 2010, p. 4). The study would be based on observations during medical consultations and follow-up, separate meetings with both to reconstruct their experiences. Interviews would take place both in the hospital and in interviewees’ homes, where they would feel more at ease to talk about questions they did and did not ask, and information they did and did not provide during the consultation. Fainzang (2010, p. 1) refers to “pressures that representatives of biomedicine exert on anthropologists” as leading to the “risk of serving as tools for public health” and losing the “critical role as a social science.” By breaking away from such pressures to conform to (bio)medical research standards and, in the friction that ensued, by being assertive about her stance, Fainzang remained faithful to the critical role of ethnography for healthcare improvement. Ultimately following the questions and research design she believed in, her work allowed for recognizing that doctors engaged in differentiated practices: they provided more information to patients who were (presumed to come) from higher social categories and withheld information from patients who were (presumed to come) from lower social categories. Interestingly, patients thought of by doctors as being in denial were also those who were given less information, which was found to further exacerbate well-known social inequality in healthcare access through social inequality in access to information. By revising questions as they were formulated in the field of healthcare and giving them a new direction, Fainzang’s work allowed for the generation of different knowledge and results on the forms and conditions of patient information, which ultimately led to new insights that were useful for healthcare improvement. Both Fainzang’s and the author’s own example studying ward culture show how conceptual frictions help formulate research questions and methodological approaches that contribute to fruitful healthcare research collaborations. Other ethnographers working in healthcare improvement might take a similar approach of ‘leaning into’ the frictions which arise at this conceptual stage to co-develop lines of inquiry which speak to both clinical and scholarly epistemologies and get to the heart of that which requires improvement. We ourselves have reflected on instances where taking this stance has been useful for developing both scholarly work and its applied impact, offering an additional example below:

Example: Diana’s Story

Diana was an ethnographer co-designing a project on healthcare staff with several clinical and institutional partners within a national public health service. Some of the partners represented a national professional body which had been leading on lobbying and industrial action for healthcare staff pay for several years. These partners were excited by the potential for ethnography to prove that pay was a significant factor in staff attrition, providing a basis of real evidence for the opinions of healthcare workers found in their annual surveys. Diana explained that ethnographic research would deeply explore the context in which the healthcare staff were working and factors that influenced their experiences and actions, but that it was not possible to design an ethnographic project that ‘proved’ pay was the problem. After a series of friction-filled discussions around insight generation and the nature of exploratory research, Diana and her colleagues were able to design an ethnographic examination which remained faithful to the ethnographic principles of contextualized practice-centric exploration. The partners were able to rethink the breadth of their own activity in lobbying holistically for improved conditions for staff, and Diana was able to tease out new theoretical insights around remuneration and concepts of value in professional health work.

Diana’s example shows that while conceptual frictions in collaborative healthcare research may be uncomfortable, they can also open space for reflexivity, dialogue, and methodological innovation. However, beyond ontological and epistemological differences, ethical tensions can also emerge when ethnographic practices intersect with clinical norms, responsibilities, and expectations. We discuss these in Section 4.

4. Ethical Frictions

Due to its historical roots and different critical focus and framings, the ethnographic worldview sees issues and their contexts differently. This may give rise to fears for healthcare stakeholders that ethnographic research might be used to evaluate and criticize some of the deeply held core tenets that guide healthcare, leading to questioning the ethnographer’s intentions and hampering efforts to build trust among the research team and stakeholders. This may be due in part to the current generation of clinician partners ‘coming of age’ professionally and undertaking medical studies during the critical realist turn of medical sociology of the 1980s and 1990s, which promoted a critical view of the role of physicians and health systems and moved social science, previously ‘in medicine’, to an outside view (Vinson, 2023). However, the fear of criticality runs deeper than the history of medical education. The participant observation that is central to ethnography requires, by its nature, a deep relationship of trust as the ethnographer is invited into the ‘inner circles’ of practice, often over long periods, but is not an insider subscribed to the same cultural norms and goals. The ethnographer’s practice is aimed at exploring the culture, worldviews, perspectives and attitudes that are embedded in the background behind policy and practice. Yet the unseen ‘context’ may be a concept that is difficult for partners untrained in social science to comprehend, value, or be able or willing to separate from policy and practice. This ‘known unknown’ can seem unfathomable to partners, and the promise of an ethnographer bringing it to light may seem threatening, or contrary to the therapeutic mission of the partner’s service or system (Arsenault, 2023).

Even where the concept of context can be understood, scientific models of transferability and generalizability can mean that the place of context, and its value in considering the realities of programs and systems, may not be agreed on by partners.

Highlighting discrepancies and gaps between the “work as imagined” of policy and the “work as done” (Hollnagel & Clay-Williams, 2022) that ethnography observes, even when performed constructively and empathetically, can be perceived as criticism. Writing about their use of ethnographic research to address the gap between a policy or protocol and practice in implementation science, Prainsack et al. (2010) illustrate a disagreement about a publication that was perceived as critiquing and, by extension, unethical. Despite bio-scientists having given permission to use quotations from interviews with them for publication, upon seeing the manuscript, they perceived it as describing their work as being messy and deviating from ideal standards, and hence sought to veto the publication. We likewise have experienced similar frictions around publication and differing ideologies around knowledge sharing:

Example: Lillia’s Story

Lillia was an anthropologist working on a long-term project exploring the organizational culture of a healthcare agency. Her work included shadowing healthcare leaders and frontline healthcare staff. The healthcare organization partner was proud of their involvement in the research and with Lillia’s selection of their hospital as a field site. However, once her research was completed and she was writing up findings to contribute to an academic article around healthcare management approaches, she was asked by the partner to withdraw her work from publication. Lead stakeholders from the partner organization stated that they were impressed with the findings and the insights they were providing to the organization—but only as long as they were “discussed internally”. Making them public through publication, even with the names of the people and organization de-identified, was perceived as a betrayal of confidential internal information. At the heart of the matter, Lillia and her partners had different disciplinary expectations about data ownership and co-authorship which meant that concepts like knowledge mobilization, impact, and dissemination were understood from different angles and were driven by different motivations. For Lillia and her partners, frictions had emerged in this case from simply being unfamiliar with the common practices of the other; Lillia worked with the partner on a knowledge mobilization plan outlining how research findings would be shared and used to create impact beyond academia, which translated into better applied impact within the sector.

In both Prainsack et al.’s and this author’s example case, the social scientists’ intention was not to criticize, but for ethnography to “take us beyond lamenting the gap [between policy and practice] and capture the relational dynamics of people working together in complex systemic arrangements” (Cubellis et al., 2021, p. 2029). The sharing of these stories via publication was the natural next step by the ethnographers to share the lessons learned and improve practice; but for those who were the focus of the ethnography, it felt private, ‘internal’, and unethical to shed light upon this. The use of storytelling is particularly illustrative of how consent in (healthcare) ethnography is an ongoing process (Murphy & Dingwall, 2007), potentially requiring ethical clearance to be revisited as participants’ understanding and comfort evolve over time. Engaging in discussions and coming to shared agreements about how and where ethnographic knowledge is made public can build trust, ensure respectful representation, and help start conversations in the very places where decisions are taken and change becomes possible.

5. Avoiding Frictions?

As discussed, early on in the research project while working to identify and to be transparent about research purposes, goals, and expectations, frictions are likely to arise between ethnographers and practitioners, researchers, administrators, and leadership in healthcare settings. Given this, decision points will arise where the researchers have the option to continue to engage in frictions—conversations and discussions that help grow the research partnership and an understanding of the value of different approaches and perspectives. Along this path, parties will make choices to either pursue the research together, allowing frictions to arise and be addressed, or to avoid frictions (or future frictions). There are two primary ways that frictions, when identified, can be alleviated. One way is through compromise. In this approach, early frictions followed by some discussion, may be identified as barriers that cannot be overcome and research directions that cannot or will not be modified. At this juncture, the ethnographer can decide to compromise and be willing to add as much value to the project as possible within the confines of this research relationship. In this way, friction may produce the growth of the ethnographer as a scholar through the exploration of new environments, new methods, or even new methodological innovations which can contribute to the discipline at large. At the core is understanding when to push frictions to inform a stronger research project and when to step back and assess the readiness of the research partners in the current context. Timing can indeed be everything. Patience and compromise today can be the first bridge to a stronger future collaboration, built on trust. Knowing the right decision and rationale is solely the purview of the ethnographer in any given project and partnership. Our own experiences have featured such methodological developments born of pragmatism and necessity, and have ultimately balanced the costs and benefits of the partnership:

Example: Marko’s story

Marko was invited to join a mixed methods research collaboration evaluating a new patient care policy. He was keen to see how the policy was translated in practice amid multiple other demands on clinicians’ time. His clinical partners valued what qualitative insights could bring to their multi-method quantitative data analysis but were unsure about the practicalities of ethnography at a large scale, a restricted budget, and all while mindful of the ethical and practical sensitivities around observing staff. Marko compromised with an amended digital ethnographic approach which allowed him to pursue some of the research questions he wanted to explore, enabled a wider scale with a lower budget, and allowed him to bring his colleagues into enriched discussions about policy and practice in the area of interest.

A second way, however, may be to fully disengage from the research project. This would likely be the case if the ethnographer feels that their contribution is so limited or so tightly confined that pursuing the research collaboration is worthless, or worse, unethical. Ethnography is often seen by health research funders, particularly in work drawing on implementation science foundations, as a key component of high-quality improvement work. As a result, for some partners, the desire for the incorporation of ethnographic work into project design as a way of appealing to funders’ preferences for an implementation science perspective may be high, but understanding or esteem of such work may not be equally so. This can result in ethnography as a ‘checklist’ item that is more important than actually conducting high-quality ethnographic work. In a systematic review of healthcare improvement intervention studies which purported to incorporate ethnographic methods, Gertner et al. (2021) found that many of these studies incorporated the ethnographer’s work, or the ethnographic method itself, only superficially. Studies showed low levels of inclusion of observational methods, little treatment of context or positionality, and, in some cases, a tendency to use the ethnographic label without incorporating any of the methods which form part of the ethnographic approach. Similarly, a scoping review of anthropological contributions to implementation science by Faro et al. (2024) indicates that while anthropologists are often involved in broader mixed-methods projects, their contributions tend to be underrepresented or only partially documented in resulting publications. In instances like these, there may be no healthy way for the ethnographer to reconcile their vision of, and commitment to, their rigorous methodological and epistemological approach with the requirements of the partner and the confines of their funding, context, research design, or scientific publication cultures. The friction in cases such as these may not be productive for a suitable collaboration or compromise for research and may best serve by producing a ground-up rethinking of the project, or even a clean point of uncoupling in the research relationship itself. We ourselves have experienced these friction points and the decision-making they spark:

Example: Jessica’s story

Jessica was asked to contribute to a research project that was examining community members’ views about access to healthy food resources. Jessica came to the meeting with ideas for meeting with the community to see what questions they wanted to ask about food access. Jessica’s position was that this would allow the study to have a more community-informed research question and to ensure the study would provide information that they thought was useful to address the problem of food access in their community. However, at the first meeting, the idea to revise the purpose of the research to one that was community-informed was met with a firm stance that this was not possible. The researchers already had a specific set of questions related to their larger study and were not interested in exploring other ways to view or address the issue of food access. Jessica made the decision at this meeting not to continue to collaborate on this research study and departed the project while still signaling a willingness to work together on future related ideas. Frictions that arose early thus led Jessica and her partners to quickly identify points where ideologically they could not collaborate to mutual satisfaction, avoiding future frictions within the research group and leaving the door open to future potential collaboration.

As Fainzang (2010, p. 41) warns, “because the aims of the two disciplines are different, in responding to the concerns of biomedicine, anthropologists run the risk of seeing their own contributions diluted. They run the risk of serving as tools for public health and of losing their critical role as a social science.” Therefore, it is essential for ethnographers to make informed decisions regarding their inputs, how they can contribute to knowledge and advance the field, and where compromise may be beneficial for both parties. Similarly, they must also know when the relationship will not be useful, or when it is not asking valuable questions, and choose to terminate the research relationship.

6. Discussion: Responding to Frictions

Understanding the value of different research traditions and questions is an important first step in any collaborative research project involving multidisciplinary researchers. This is particularly true for ethnographic research, which aims more than any other qualitative research to seek out the emic perspectives of stakeholders within the research, be they patients, practitioners, or policymakers, and the range of methods it may incorporate in its development of evidence among different ontologies (Savage, 2006).

We suggest beginning collaborations with each partner by clearly laying out their research purpose, goals, and related design approaches. All involved parties should then discuss the value of these and how they will add value to the study findings. Conducting this process early and revisiting it regularly is fundamental for researchers to reach a shared consensus on the research problem. Consensus does not require the different parties to come to a full agreement but rather integrates different viewpoints in a way that “makes sense [for all participants], encompasses what they think to be relevant, is coherent and consistent to them, does not contradict their beliefs, and is commensurable to their approaches” (Defila & di Giulio, 2017, p. 333). In such collaborative framings, simultaneous forms of reasoning, or ‘heterologoi’, are unavoidable. With this term, Rabinow (2003) refers to multiple, potentially conflicting yet equally valid logics or interpretations of a social situation. Early discussion to try to achieve consensus lies at the heart of successful collaborations in healthcare ethnography, as it adds clarity to the varied conceptual approaches that inform research questions and methodologies. It can either set the stage for successful collaboration or identify frictions and cross purposes that may stymie the project, and it can help researchers make an informed decision regarding the benefit of collaboration, including if it might be better not to collaborate. Early consensus also sets the basis for research results to later rise above the mere addition of contributions from separate approaches (Defila & di Giulio, 2017).

In responding to frictions, ethnographers may ‘lean into’ them early and productively. This may involve openly sharing the questions ethnography asks, methods, and goals that may be fruitful within a research team that is open to exploring different questions that may look beyond the originally envisioned research project. Another way to share the ethnographic lens might be to involve clinical partners in early meetings with communities or patient groups, including how study involves community partners from the early stages of defining research questions, methods, data collection, and interpretation. Partners may even be involved in assisting with data collection as a pathway to share the ethnographic approach, as Shand et al. (2021) did by training key clinical stakeholder’s ‘learning coordinators’ in how not to just oversee staff learning but to directly learn from staff through ethnographic observation. Early and ongoing involvement in the method of ethnography can help demystify the approach and can help collaborators feel more comfortable with the process.

If a study has moved forward with little early discussion, minimal friction, and data collection is in process, another way to help ensure ongoing synergy is by sharing ethnographic findings early with collaborators. If there may be issues with questions being asked or data being collected, this is the time to share and discuss the rationale and usefulness while there is time for collaborators to ask questions and understand how the data contributes to the overall study. Frictions are likely to arise at this point, particularly if data reflects the clinical collaborators who are representatives of the field site or service themselves. Defensiveness can be a natural response to early results that raise questions about or challenge practice or deeply held beliefs. At this stage, the ethnographer can lean into these frictions by collaboratively reflecting with the clinical partner on where the defensive response comes from. This helps to enrich the interpretation of findings by generating more insights into the broader context (Bieler et al., 2021), and can help the clinical and/or healthcare setting collaborator feel that their response is valid and that the ethnographer is open to thinking through it. It is also important to discuss how research collaborators want to be included as co-authors of manuscripts, so that their interpretations and possible concerns, should they wish, are included as a part of the ethnography. It may not always be possible to have all collaborators agree on interpretations of data. Just as ethnographers include the perspectives of the people and communities with whom they are working to interpret data and contribute to manuscripts, it is also important to co-create dissemination products with members of the research team. In fact, it is the richness of different perspectives and grappling with different interpretations that leads to the most thoughtful ethnographies.

7. Conclusions

In this paper, we have reflected on the productive potential inherent in frictions as allowing the field to move forward. In ethnography for healthcare improvement, friction speaks to interactions between teams, between individuals, and between disciplines, which is applicable to different levels of organizational innovation and transformation work. Friction allows us to look beyond differences in epistemological and ontological stances and clashes about assumed underlying ethics. Talking about frictions shifts the conversation away from the battle to prove the value of ethnography in healthcare settings and toward recognizing where and how we can make an impact with ethnographic research. Friction, we argue, is a key part of interdisciplinary collaboration to address uncomfortable yet crucial issues within healthcare organizations and be truly transformative. Progress, in healthcare improvement, can only be made through friction.