Table 1

Study design and approach using VRE

Ethnographic observationDS (academic GP/social scientist), NF (social anthropologist) both experienced ethnographers in health settings and LH (speech and language therapist undertaking an ethnographic PhD) spent 422 hours observing practices relating to medicines management across the three GP sites and recruited a cohort of 24 patients, aged 65+ who were prescribed 10 or more items of medication (site A n=7, site B n=10, site C n=7). Our general practice observations enabled us to shadow staff and follow organisational routines relating to medicines. We followed patient participants ethnographically for a period of 18–24 months observing their lived experiences of multimorbidity, polypharmacy and healthcare services.September 17 to March 20
Filming medication reviews/consultations where medications were discussedDS, LH, NF accompanied study patients to 29 selected clinical consultations when we anticipated discussion of patients’ medicines. NF and LH video-recorded 18 consultations. In addition to consent to taking part in the wider APOLLO-MM Study, all participants (patients and practitioners) involved in video-recorded consultations engaged in a further consent process before and after the consultation ensuring full understanding of how video data would be used. 11 practitioners (site A n=2, site B n=3, site C n=6) and 11 patients (site A n=3; site B n=3; site C n=5) took part in 18 video-recorded consultations. The duration of the video-recorded consultations ranged from 5 to 32 min (mean=17 min).June 8 to February 20
Video analysis and selecting critical momentsDS and NF viewed each video-recording independently multiple times, identifying ‘critical moments’, then met to discuss and refine our selection as we prepared video clips to share with practitioners in VRE workshops. Each researcher drew up tables identifying sections of potential interest in the footage, a brief description, and a rationale for selecting this footage as a ‘critical moment’. We did not strictly define what might constitute a ‘critical moment’ a priori, but this iterative process brought together:
  • Our research interest in how practices ‘on the ground’ constitute, sustain or challenge polypharmacy

  • Insights derived from our ethnographic observations of patients and practitioners about how polypharmacy is ‘done’

  • Moments of communicative interest (eg, misunderstandings; the evolution and emergence of decisions; occasions when the direction of the consultation appeared to ‘turn’)

  • ‘professional noticing’38—moments in which clinicians exercised their professional vision in action (eg, selecting, interpreting and responding to relevant events to support patient care)

  • Footage that might extend or illuminate insights that emerged through professional dialogue in previous VRE workshops

This was an iterative process, occurring alongside ongoing data collection and delivery of VRE workshops. Clips were selected for their potential to invite discussion regarding ‘ordinary’ practice.
November 18 to February 20
Reflexive workshopsThis was a flexible and dynamic process, each 1 hour VRE workshop contributing not only to our evolving understanding of polypharmacy and its practices, but also to our understanding of how to maximise the potential of the VRE methodology to realise the complexity of polypharmacy and stimulate practitioners to engage in productive dialogue across our three settings (eg, we discovered that the shortest video clips—even those of 11 s—were often most effective at supporting reflexivity).
We often played clips several times (guided by participants) and used different clips in each workshop. We provided written prompts to stimulate discussion, which participants used to varying degrees:
  • What’s happening in this clip?

  • What do you notice?

  • Does anything surprise you?

  • How do you feel when you watch this footage?

  • Is there something that this clip does NOT show that is important for understanding what is going on?

VRE workshops were audio-recorded and transcribed.
June 19 to March 20
Participant reflection and evaluation of VRE workshopsAt the end of the third (final) workshop at sites A and B we spent 15 min inviting the participants’ reflections on the VRE approach. Participants also completed a short written reflective activity identifying the most important thing they had learnt from taking part and something they would consider doing differently as a result of the VRE workshops.February 20 to March 20
Analysis of VRE transcriptsAfter repeated reading and familiarisation we identified ‘moments of potentiation’ and traced how these played out within workshops. Our analysis was iterative, enabling us to tailor our selection of video clips to deepen our insights as workshops progressed. Once all workshops were complete we conducted further rounds of analysis, honing in on shifts in how polypharmacy and medication review practices were articulated and understood by participants through their participation in the VRE process, identifying key themes across the data set.June 19 to October 21
  • APOLLO-MM, Addressing the Polypharmacy Challenge in Older People with Multimorbidity; GP, general practitioner; VRE, video-reflexive ethnography.