Iran Journal of Nursing

Introduction
Institutional ethnography (IE), an alternative approach to research introduced by Canadian sociologist Dorothy Smith, focuses on the daily lives of individuals and how these lives are structured and coordinated by institutional forces. One of the main assumptions of the IE is that the individual experiences of people are connected to and shaped by the larger power relations. Therefore, IE emphasizes the integration of individual and social contexts and sees social life from the perspective of marginalized individuals. The IE seeks to understand and record the details of the work processes performed by organizational members and then trace how these processes are coordinated at a higher level by policies, practices, standards, frameworks, and social norms. People may or may not be aware of these higher-level influences on their work. Discovering and elucidating the dissonance between what institutions think people (their stakeholders) should do and what people are actually doing is of interest to an IE researcher. 
Despite the wide use of qualitative methods such as discourse analysis, grounded theory, and phenomenology, IE has received limited attention in the studies. This study aims to introduce the terminology, concepts, and key insights of IE by reviewing the published articles.

Methods
In this review study, to find the related articles, a search was conducted in PubMed, Scopus, Web of Science, Cochrane Library, Iranian Scientific Information Database (SID), and Google Scholar, without a specific time limit, using the keywords "institutional ethnography", "health care system", and "delivery of health care" in Persian and English by employing the Boolean operators (AND, OR). The reference section of retrieved articles was also manually examined. Articles were screened by titles, abstracts, and then full texts. Finally, the eligible articles and books were reviewed.

Results
The IE researcher can employ a range of data collection techniques to explore the experiences and identify the problem. Some key terms for IE included Disjuncture, Explicate, Problematic, Ruling relations, Standpoint, Texts, and Work. The process of IE can be divided into four stages: 
i. Identifying the disjuncture and problematic: The IE studies usually start with identifying a disjuncture, which refers to the dissonance between individuals' experiences in the real world and the official representation of these experiences. IE is suitable for busy clinicians who want to address a problem they have observed or experienced in the workplace, especially those expected to happen officially but do not happen in practice. 
ii. Data collection methods: The methods for data collection in IE included observation, interviews, focus group discussions, and the identification of "local" and "extra-local" texts that coordinate people's work processes. Observation enables researchers to collect data about emotional expressions, interactions between people, and time spent on different activities. Institutional ethnographers generally do not prioritize observation as a data collection method like traditional ethnographers, but place a higher value on interviews and textual analysis. A text can be any type of document on paper, computer screen or in computer files. It can also be a drawing, photograph, printed matter, video, or sound recording. One effective way for an interviewer is to sit down with the informants and the target text and talk about what is in the text and how the informants work with it.
iii. Data analysis: This stage involves describing the details of the work processes of the individuals and tracing their daily activities through extra-local texts to explain the governing relations that organize their work. Institutional ethnographers tend not to use formal analytic strategies. The IE researcher listens for clues (experiences) of social organization and then follows these "threads" to understand how institutional power relations are used to structure people's everyday experiences in ways that may not even be anticipated. To analyze the obtained texts, two approaches proposed by Smith included sequential and hierarchical methods. To clarify this path as much as possible, mapping, indexing, and creating preliminary accounts/analytic chunks are used. By using the IE methodology tools (Standpoint, Ruling relations, and Problematic), the IE researcher collects data based on a "storytelling" approach in such a way that the starting point is the facts of people's daily experience. In the end, it connects the facts to the social organization that governs the local environment.
iv. Useful recommendations and conclusions for changing practice: The findings from the analysis are used to make recommendations for changes in practice.

Conclusion
Institutional ethnography is a valuable qualitative method that allows healthcare professionals and researchers to trace everyday work processes to higher-level coordinators, such as organizational leadership and management, that individuals may or may not be aware of. We recommend that healthcare providers employ IE in contexts where they encounter organizational issues full of contradictions and disjunctures. This method is particularly useful in cases where individuals observe social relations that constrain everyday practice or where students, faculty members, clinicians, or patients frequently mention "gaps and disjunctures" within and between systems.

Ethical Considerations
Compliance with ethical guidelines
In this study, all related ethical principles were considered. This is a review study with no experiments on human or animal samples. Therefore, no ethical code was obtained. 

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions
Farzaneh Mokhtary conducted the search in databases and prepared the initial draft; Leila Jouybari administered the project, edited, and reviewed the manuscript; Abouali Vedadhir and Akram Sanagoo supervised, edited, and reviewed the draft.

Conflict of interest
The authors declare no conflict of interest.


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