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Embedding hospital-based medication review: The conflictual and developmental potential of a practice
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
Linköping University, Department of Thematic Studies, Department of Child Studies. Linköping University, Faculty of Arts and Sciences.ORCID iD: 0000-0003-0587-3399
Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.ORCID iD: 0000-0001-5066-8728
Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.ORCID iD: 0000-0001-9116-8156
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. Vol. 33, no 3, p. 339-352
Keywords [en]
Patient safety, Qualitative research, Implementation, Medical professions, Ethnographic methods, Medical practice
National Category
Public Health, Global Health, Social Medicine and Epidemiology Nursing
Identifiers
URN: urn:nbn:se:liu:diva-156644DOI: 10.1108/JHOM-09-2018-0268ISI: 000471054500005Scopus ID: 2-s2.0-85064750614OAI: oai:DiVA.org:liu-156644DiVA, id: diva2:1313200
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
In thesis
1. Embedding Medication Review in Clinical Practice: Reconceptualising Implementation Using a Practice Theory Perspective
Open this publication in new window or tab >>Embedding Medication Review in Clinical Practice: Reconceptualising Implementation Using a Practice Theory Perspective
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
Ethnographic approach; practice theory; professional practice; sociomateriality; implementation; medication safety; patients; organization
National Category
Medical and Health Sciences Other Health Sciences
Identifiers
urn:nbn:se:liu:diva-156274 (URN)10.3384/diss.diva-156274 (DOI)9789176850657 (ISBN)
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, 626451
Available from: 2019-05-02 Created: 2019-04-10 Last updated: 2019-05-07Bibliographically approved

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