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Embedding Medication Review in Clinical Practice: Reconceptualising Implementation Using a Practice Theory Perspective
Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.ORCID iD: 0000-0002-8782-0751
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The hospital is a critical setting with respect to medication safety and quality of medication therapy. Medication review, the structured assessment of an individual patient’s medications with the aim of improving therapy, has been advocated as a strategy to reduce medication-related harm. Although programs of medication review have been widely introduced, its implementation has encountered difficulties. While seemingly a rather straightforward concept, processes to identify current medication use and reconcile different medication lists have been complicated by organizational, interprofessional, or technical factors. There is, thus, a need to better understand medication review implementation. However, it is also important to critically consider how the implementation of healthcare interventions is generally understood, and what theoretical or conceptual considerations inform implementation efforts. Studying organizational and social phenomena as they unfold in practice has the potential to shed light on how these everyday activities are generated, how they are adapted over time, and what consequences this has on social and organizational processes.

The purpose of this thesis is to develop an alternative perspective on studying the implementation of a healthcare intervention in routine care. More specifically, this thesis aims to theorize the embedding and practicing of medication review in routine hospital work. Theorizing, here, refers to empirically and theoretically exploring phenomena based on cases of local medication review implementation.

Drawing on empirical case examples of medication review implementation in southeast Sweden, an ethnographic approach is employed conducting participant observation, informal conversations and semi-structured interviews with different healthcare professionals in two hospital settings, as well as semi-structured interviews with patients from three different hospital settings. A so-called toolkit approach for practice theory is employed, using a range of different practice-theoretical concepts to empirically study practice.

The empirical findings point to the centrality of dealing with medication-related problems when conducting and embedding medication review. Both practicing and embedding medication review were shaped by how medication-related problems and potential medication harms were constructed, contested, and negotiated in practice. Practitioners’ everyday actions and practices revealed different meanings attached to the concept of medication-related problem bringing to the fore the contested and conflictual nature of the practice. Also, insight was provided into how practices to embed medication review in routine hospital work unfolded, revealing material-discursive and reflective practices, but also silent modes of legitimizing the ‘non-practicing’ of medication review in a highly structured way.

This thesis provides an alternative perspective on studying the implementation of a healthcare intervention and challenges various assumptions underpinning implementation research. Instead, a broadened perspective is suggested directing attention to the practical and situated knowing involved, the local processes of negotiating objectives in practice, as well as to the meaning-making required when practitioners engage with a practice. Finally, there are opportunities to learn from implementation processes, when frontline practitioners involved in embedding medication review are able to reflect on adapting medication review to make routines better fit the local context.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2019. , p. 98
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1684
Keywords [en]
Ethnographic approach; practice theory; professional practice; sociomateriality; implementation; medication safety; patients; organization
National Category
Medical and Health Sciences Other Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-156274DOI: 10.3384/diss.diva-156274ISBN: 9789176850657 (print)OAI: oai:DiVA.org:liu-156274DiVA, id: diva2:1303738
Public defence
2019-06-04, Hasselquistsalen, Hus 511 , Våning 9 , Ingång 76 ,78, Campus US, Linköping, 09:00 (English)
Opponent
Supervisors
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2014-4657Medical Research Council of Southeast Sweden (FORSS), 476971Medical Research Council of Southeast Sweden (FORSS), 568651Region Östergötland, 533151Region Östergötland, 626451Available from: 2019-05-02 Created: 2019-04-10 Last updated: 2019-05-07Bibliographically approved
List of papers
1. Our surgeons want this to be short and simple: practices of in-hospital medication review as coordinated sociomaterial actions
Open this publication in new window or tab >>Our surgeons want this to be short and simple: practices of in-hospital medication review as coordinated sociomaterial actions
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2018 (English)In: Studies in Continuing Education, ISSN 0158-037X, E-ISSN 1470-126X, Vol. 40, no 3, p. 323-336Article in journal (Refereed) Published
Abstract [en]

Medication review, a systematic assessment of a patients medicines by a health care professional, is intended to prevent medication-related harms. A critical element of medication review concerns whether medication review is conducted in a coordinated way. This article draws from a case example of implementing medication review in two surgical wards of a Swedish regional hospital and aims to analyse how medication review is being accomplished with respect to the coordination of its actions. Using a practice-based ethnographic approach, we present several coordination mechanisms by illustrating how practices are connected to materials involved in medication review. Also, we show how common orientations, ends, and understandings expressed in different medication review practices contribute to the coordination of the practices. In conclusion, this article highlights the complexity of establishing and sustaining medication review as a coordinated practice in routine health care. By closely examining sociomaterial connections, this article sheds new light on the neglected issue of artefacts and arrangements in constituting and transforming a highly complex medication practice.

Place, publisher, year, edition, pages
ROUTLEDGE JOURNALS, TAYLOR & FRANCIS LTD, 2018
Keywords
Ethnography; practice theory; sociomateriality; coordination; medication safety; implementation
National Category
Pedagogy
Identifiers
urn:nbn:se:liu:diva-151230 (URN)10.1080/0158037X.2018.1458710 (DOI)000442433800007 ()
Note

Funding Agencies|Swedish Research Council for Health, Working Life and Welfare (Forte) [2014-4657]; Medical Research Council of Southeast Sweden (FORSS) [FORSS-476971, FORSS-568651]; County Council of Ostergotlands patient safety research fund (Region Ostergotlands Medel for Patientsakerhetsforskning) [LIO-533151, LIO-626451]

Available from: 2018-09-13 Created: 2018-09-13 Last updated: 2019-04-10
2. Medi(c)ation work in the emergency department: Making standardized practice work
Open this publication in new window or tab >>Medi(c)ation work in the emergency department: Making standardized practice work
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2018 (English)In: Professions & Professionalism, ISSN 1893-1049, E-ISSN 1893-1049, Vol. 8, no 2, article id e2298Article in journal (Refereed) Published
Abstract [en]

Medication review, the systematic examination of an individual patient’s medicines in order to improve medication therapy, has been advocated as an important patient safety measure. Despite widespread use, little is known about how medication review is conducted when implemented in routine health care. Drawing from an ethnographic case study in a Swedish emergency department and using a practice-based approach, we examine how medication review is practically accomplished and how knowledge is mobilized in everyday practice. We show how physicians construct and negotiate medication safety through situated practices and thereby generate knowledge through mundane activities. We illustrate the centrality of practitioners’ collective reflexive work when co-constructing meaning and argue here that practitioners’ local adaptations can serve as important prerequisites to make “standardized” practice function in everyday work. Organizations need to build a practical capacity to support practitioners’ work-based learning in messy and time-pressured  health care  settings.

Keywords
practice-based study, ethnography, practical knowledge, professional practice, medication review, implementation, patient safety
National Category
Other Health Sciences
Identifiers
urn:nbn:se:liu:diva-151815 (URN)10.7577/pp.2298 (DOI)
Available from: 2018-10-04 Created: 2018-10-04 Last updated: 2019-05-01
3. Embedding hospital-based medication review: The conflictual and developmental potential of a practice
Open this publication in new window or tab >>Embedding hospital-based medication review: The conflictual and developmental potential of a practice
2019 (English)In: Journal of Health Organisation & Management, ISSN 1477-7266, E-ISSN 1758-7247, Vol. 33, no 3, p. 339-352Article in journal (Refereed) Published
Abstract [en]

Purpose: The purpose of this paper is to explore the embedding of hospital-based medication review attending to the conflictual and developmental nature of practice. Specifically, this paper examines manifestations of contradictions and how they play out in professional practices and local embedding processes.

Design/methodology/approach: Using ethnographic methods, this paper employs the activity-theoretic notion of contradictions for analyzing the embedding of medication review. Data from participant observation (in total 290?h over 48 different workdays) and 31 semi-structured interviews with different healthcare professionals in two Swedish hospital-based settings (emergency department, department of surgery) are utilized.

Findings: The conflictual and developmental potential related to three interrelated characteristics (contested, fragmented and distributed) of the activity object is shown. The contested nature is illustrated showing different conceptualizations, interests and positions both within and across different professional groups. The fragmented character of medication review is shown by tensions related to the appraisal of the utility of the newly introduced practice. Finally, the distributed character is exemplified through tensions between individual and collective responsibility when engaging in multi-site work. Overall, the need for ongoing ᅵrepairᅵ work is demonstrated.

Originality/value: By using a practice-theoretical approach and ethnographic methods, this paper presents a novel perspective for studying local embedding processes. Following the day-to-day work of frontline clinicians captures the ongoing processes of embedding medication review and highlights the opportunities to learn from contradictions inherent in routine work practices.

Place, publisher, year, edition, pages
Emerald Group Publishing Limited, 2019
Keywords
Patient safety, Qualitative research, Implementation, Medical professions, Ethnographic methods, Medical practice
National Category
Public Health, Global Health, Social Medicine and Epidemiology Nursing
Identifiers
urn:nbn:se:liu:diva-156644 (URN)10.1108/JHOM-09-2018-0268 (DOI)000471054500005 ()2-s2.0-85064750614 (Scopus ID)
Note

Funding agencies:  Swedish Research Council for Health, Working Life and Welfare (Forte) [2014-4657]; Medical Research Council of Southeast Sweden (FORSS) [FORSS-476971, FORSS-568651]; County Council of ostergotland patient safety research fund (Region ostergotlands Medel f

Available from: 2019-05-02 Created: 2019-05-02 Last updated: 2019-07-15Bibliographically approved

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