Getting prescription medications right at home, in hospital & hospice

An activity theory analysis to improve patient safety and confidence in palliative care

Background

Approximately 20% of NHS serious incident reports involving palliative patients relate to prescription medications. Underlying causes and contributing factors are poorly understood.

Historically established divisions of labour and normative rules (practice etiquette) shape prescribing and medication use. Process disturbances mean the experience does not always match the outcome intended in healthcare practice, for example, due to boundaries and misunderstandings between different groups and roles. Patient behaviour adds additional complexity, for instance, if they accept or reject medications, and patients are commonly the only constant across home, hospital and hospice contexts. Thus, prescribing and medication use is a multi-step process requiring coordination of many organisational systems, enacted through professionals, patients and carers. This study is the first to use patients’ activity systems as its unit of analysis, within and across the contexts of home, hospital and hospice, to investigate and model practices of prescribing and medication use for symptom control (incorporating everything necessary to get the right medication at the right time).

Aim

To compare intended /‘what happens on paper’ processes with experienced/‘what happens in the real world’ practices identifying when, how and why process disturbances in prescribing and medication use impact on quality and safety.

Research questions

1. What are the experiences of patients, carers and professionals of prescribing and medication use in palliative care in and during movement across home, hospital and hospice?
2. How does the division of labour and practice etiquette between professionals, carers and patients reinforce or destabilise prescribing and medication use practices and what impact does this have?

Objectives

1. To develop a practice-based model for the multi-step task of prescribing and medication use in palliative care
2. With this model, to identify and develop an extended understanding of disturbances and safety concerns for patients within or when moving across hospice, hospital, and home
3. To develop a multi-perspective understanding of 'hot' (attracting attention, viewed as problematic by participants) and 'cold' (not attracting attention from participants, observed as problematic by research team) spots in processes and practices of prescribing and medication use for palliative care
4. To use understanding of practice disturbances to create a learning, analysis and recommendation toolkit identifying targets for innovation and improvement.

Methodology

The study used the conceptual tools of Activity Theory to study effort (work/activity) for prescribing and medication use. This entailed analysing real-life practices during palliative care and how these compared to intended processes described in care guidelines and service models. Activity Theory identifies and analyses contextualised historically established divisions of labour and disturbances in working practices with a shared object (goal), in this case achieving symptom control through accurate and effective prescribing and medication use. Understanding disturbances is key to improving outcomes.

Phase 1: Scoping review to develop a visual model illustrating intended process in typical prescribing/medication use episodes within and across three contexts: home, hospital and hospice.

Phase 2: Direct observation of everyday practice (3x1 week), conducting informal conversations around the acts of prescribing and medication use in each context prior to purposive sampling of patients and informal carers (n=30(15x2)) and healthcare professionals (n=40) for qualitative semi-structured interviews. Data collection methods included field notes, audio-recordings, and pictorial representations of processes. Identified disturbances and risks were explored and categorised (objective 2). Analysis of multiple perspectives created an understanding of actual prescribing and medication use processes (objective 3).

These were mapped to the initial model expanding it into an authentic practice-based model for the whole multi-step task (objective 1) which can be used to identify targets for improvement interventions (objective 4).

This study was approved by the London - Camden & Kings Cross Research Ethics Committee (21/LO/0459). A patient and public involvement (PPI) co-applicant was involved in designing and delivering the study. A steering group oversaw the study and a PPI engagement group worked with the research team.

Funding

This work was supported by a Marie Curie Research Grant [MC-19-904].