Video-reflexive ethnography (VRE): a promising methodology for interprofessional collaborative practice research

Introduction

This issue of the Journal of Interprofessional Care presents exceptional research undertaken by Carroll et al. (2021) in the USA and Pedersen and Mesman (2021) in the Netherlands utilizing Video-Reflexive Ethnography (VRE). Carroll et al. present research completed at the Mayo Clinic involving the breast cancer surgery team and the frozen section laboratory team in scrutinizing video footage of their interprofessional collaborative practice: breast tissue is surgically removed and sent to the lab for testing, and biopsy results are made available soon after to the surgeons to enable them to decide whether to finish their operation or continue the surgery. The clinical outcomes of this Mayo Clinic practice include the lowest reoperation rates for breast lumpectomy in the USA.

Pedersen and Mesman (2021) delve deeper into the underlying methodological assumptions and arugments for VRE, using an example from a video-reflexive meeting at a neonatology ward in a Dutch hospital during which clinicians discussed the use of sterile gloves. Specifically, Pedersen and Mesman draw on John Dewey’s writings to position patient safety, and interprofessional collaborative practice, as a transactional accomplishment dependent on situated and shared habits whereby humans and their environments are inseparably linked.

It is important to note that the health professionals’ participation in these video studies was not motivated by an incident, nor by their conviction of being able to having achieved an exemplary standard. They participated out of interest in what a videoed perspective on their practice might yield, no doubt in light of VRE enjoying growing popularity in health care improvement initiatives around the globe (Iedema et al., 2019).

Harnessing complexity

On the principle that top-level athletes, musicians and performers make regular use of video reflexivity to strengthen their knowledge of and grip on their own performance of ultra-demanding tasks and complex challenges, the US Mayo Clinic and Dutch neonatology teams signed up to VRE research to identify opportunities for fine tuning their already outstanding practice. As the two research studies demonstrated and as their articles reveal, video footage was able to make visible to those who perform it aspects of their own practice that had remained invisible to “the naked eye”. What became apparent to professionals engaged in this video-reflexive process were two significant realizations: their practice was extremely complex, and there was a hard-to-detect logic that justified and explained that complexity (Carroll et al., 2021).

Commonly, amidst the hurly-burly of everyday clinical work, complexity is judged against taken-as-given expectations (“this should not be so hard”), and is experienced as meaningless noise that degrades practice (“it’s chaos”). When viewed on video, this complexity reveals itself with nuance and clarity. Instead of necessarily representing an impediment to safety, progress and interprofessional collaboration, complexity may (as it did in these two papers) show itself to be integral to the structure and flow of collaborative activity, the role of the resources that are woven into the fabric of that activity, and the nature of the communication and relationships that support that activity. Framed in this way, complexity becomes visible as no longer an external threat and an enemy of simplicity and standardization. Instead, complexity reveals itself to be a logical aspect and meaningful consequence of how we organize and structure activities, resources and relationships.

The video-reflexive meetings that Carroll et al. conducted in the USA showed this very insight to be enabling for participants in four important ways (Iedema et al., 2019). First, participants recognized that their own situated performances harbor and shelter complexity that heretofore may have been experienced as “inevitable” due to external factors and actors. Second, they understood that this complexity is not pure chaos, but has identifiable (local and more distal) origins, logic and predictability. Third, they acknowledged this complexity to warrant their attention and perhaps, on occasions, their intervention. Fourth, they felt energized by this newly-found complexity as it engages them in locally, personally and organizationally unique ways. That is, their agency as human actors was both confirmed and necessitated through these newly-attained insights into the complex nuances and dynamics of their practice.

Thus, Carroll et al.’s (2021, p. 8) study reports on a “complex dynamic of cross-professional and cross-hierarchical information exchange” that, while enacted by the teams, had not been apparent to them. The reflexive sessions were thus instrumental in enabling “the pathology and surgical team to newly ‘see’ that while assigning priority to incoming […] specimens and conducting the necessary evaluative and communicative work with the [surgical team], [the pathology team] were also enacting communications about other specimens for other specialty areas” (Carroll et al., 2021, p. 8). At the same time, this complexity was realized to bear out a practical function, a logic. Thus, marveling at how complex juggling of specimens enabled the pathologists to continually triage tasks, the surgical participants exclaimed: “how much more you guys are juggling in the lab, it’s not just the specimen, it’s all these other specimens coming and going and colorectal cases and gyn” (Carroll et al., 2021, p. 8). Thus, it became clear that the lab pathologists’ non-linear work patterns serve to manage the constantly changing “field of play” created by incoming pathology tasks necessitating constant reassessment of urgencies and reconfiguration of lab imperatives and task sequences.

Similarly, Pedersen and Mesman’s (2021) video-reflexive session on using sterile gloves in the Dutch neonatology ward led to health professionals initiating concrete practice improvements such as ending the use of a lesser brand of gloves and purchasing additional trolley tables. It also led them to a “re-awareness of the gloving procedure, a new attention to the importance of the packing of the gloves for sterility, and a more general awareness of gloving as a continual accomplishment based on the intertwinement between person, team and environment” (Pedersen & Mesman, 2021, p. 8). For example, the team appreciated how sterile gloving also involves turning on the lights, washing hands, the collaborative element of putting on the gloves, and the requirement for a suitable and clean surface. Further to practice improvement, the neonatology team members found the use of VRE on their unit helped them “confront each other” when practices required correction because they could refer to the reflexivity sessions. In this way, the video-reflexive sessions had longer-lasting effects on shared interprofessional team learning and habituation.

With this reevaluation of complexity as a critical enabling aspect of situated practice comes the reassessment of practice per se. The two studies delicately describe how video reflexivity complexifies professionals’ and researchers’ appreciation of and interactions with specialized performance and expert practice. VRE thus raises people’s ability, confidence and inclination to ascertain and intervene in heretofore unnoticed dynamics in “complexity-pertinent” ways (Iedema, 2019). It enables professionals and researchers to move on from simplistic understandings of practice, and leave behind binary oppositions promoted in the quality and safety literature between failure and achievement, intention and execution (Hollnagel et al., 2015). These distinctions become ineffectual once we gain insight into the complexity of in situ practice, and into the ubiquity of that complexity. Having witnessed the unfolding of care on video, we realize that right-wrong simplifications no longer offer adequate purchase on the complex dynamics and radical density of situated human practice.

Through the use of video, seemingly mundane and routine activities can reveal habituated practices, reactions and skills taken for granted, and complex interprofessional transactions that make up every day clinical situations. Building on Pedersen and Mesman’s (2021) argument, interprofessional practice may be seen as an ongoing, situated, and co-constructed achievement which is not attributable to any individual factor; rather, it is a thoroughly collaborative accomplishment. In this way, the use of video as a method can play an important role in capturing the situated work practices at play in interprofessional collaborative activity.

Conclusion

It is now almost two decades since VRE began to be deployed with healthcare professionals, patients and services (Iedema et al., 2006). Each VRE iteration has shown participants’ learning to strengthen their agency and their interventions (see Iedema et al., 2013 for international examples). Their learning moreover has been shown to not just apply to the practice or organization scrutinized, but to practices and organizations generally (Iedema et al., 2009). Indeed, VRE is recognized as engendering among participants a general inclination, confidence and ability to co-organize care thanks to their emerging observation of “what is”. Close observation of “what is” using video is instrumental here: it releases us from the compulsion to subject care to rules and measurements or to opaque claims about service resilience. VRE involves participants in developing complexity-sensitive and interprofessional attitudes to learning and working – attitudes that are increasingly critical for how we conceptualize, enact and intervene in health care in the contemporary age.

As a situated methodology, VRE offers an exciting approach that can help interprofessional scholars and clinical teams to explore and benefit from shared practices and concerted accomplishments. It offers opportunity for shared interprofessional inquiry, which can lead to the development of new insights and approaches to collaborative practice based on otherwise unnoticeable transactions in the day-to-day work of the interprofessional team.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.