Patient experiences and practices

We will follow patient participants ethnographically over 18–24 months, observing them at home and accompanying them to selected healthcare interactions in which they anticipate talk about their medicines (eg, at the GP surgery, pharmacy or hospital). We are conducting interviews with patients to elicit the story of their lives since they were first advised to take medicines, adapting Wengraf’s Biographic-Narrative Interpretive Method.26 This approach utilises a single question to induce narrative and invites participants to speak uninterrupted until their story is complete. After a short break (10–15 min), the researcher presents a series of further questions based on ‘cue phrases’ (the patient’s own words) in the order the patient introduced them into their opening narrative, to encourage further in-depth narratives (particular incident narratives). On a separate occasion, we return to the patient’s home to conduct an in-depth interview guided by a topic guide with a more explicit focus on medicines practices. We contact participants by telephone or home visit at approximately 4–8 weekly intervals to learn about their ongoing experiences and to identify occasions when we may accompany them to a healthcare interaction or video record a consultation. Every time we meet our participants, we take detailed ethnographic field notes, add to our reflexive journal and gather relevant documents (eg, discharge summary or lists of medication). This data enables us to build detailed patient case studies as we follow their lived experience and engage them in informal ‘event-based’ interviews exploring their care experiences.

A subset of patients are completing cultural probe activities as a way of depicting their lives. Cultural probes originated in the world of design as a way of tapping into peoples’ creativity and offering research participants opportunity to engage in a research-related activity that is subjective, deliberately ambiguous, open to interpretation, invites imagination and stimulates conversation.27 28 The probes consist of a set of activities and a range of materials (eg, camera, pens, cards, booklets) with simple instructions which offer opportunity for improvisation. They encourage participants to think about their medicines and bodies in new ways and reimagine possibilities for how they might interact with health professionals. The creative outputs are used to stimulate an informal discussion between researcher and participant. Participants may invite a family member or researcher to assist if they wish. Cultural probes have been used successfully to incorporate older people’s ideas into the design of social communities27, and to illuminate the daily living needs of older people to inform co-production of assistive living technologies,29 30 although it is recognised that some people may be unable to engage with them for a range of physical, emotional and social reasons.29

Professional experiences and practices

We will conduct ethnographic observations in three GP and four community pharmacy practices (see figure 1). Our interest is in understanding how health professionals conduct and make sense of their day-to-day work of prescribing, dispensing, negotiating, organising medicines for patients affected by polypharmacy. We will observe key routines such as preparation and organisation of multicompartment compliance aids (MCAs or ‘dosette boxes’); repeat prescribing and repeat dispensing.

We will closely observe individuals at work (shadowing and asking participants to describe what they are doing as they do it to encourage the articulation of tacit knowledge); organisational routines and how they are constituted; the wider institutional context and documents relevant to the work we observe (eg, prescriptions, guidelines). We will also interview key professional participants across our sites with a focus on accounts of their working practices. We will hone in on consultations between clinicians and our study patients to examine healthcare interactions in detail by video recording consultations in which our participants anticipate ‘talk about medicines’. The polypharmacy context is a very particular context for these interactions and we are interested to learn how polypharmacy is sustained, challenged, talked about and ‘brought about’ in these interactions.

Organisational routines are conceptualised as ‘repetitive recognisable patterns of interdependent actions by multiple actors’31 32 and can be regarded as sites of stability and as sites of potential for innovation and change.33 When participants engage in routines they enact tacit knowledge and are involved in complex patterns of collaboration—involving people, artefacts, technologies—to get work done. Routines can be embodied, embraced, resisted and enacted with varying degrees of creativity and improvisation and varying attention to the particularities of local context.34 Pentland and Feldman have conceptualised routines as being composed of:

• Ostensive routines: the generalised ‘rules’ or organisational scripts that guide the routine, of which there may be many instantiations.

• Performative routines: what people actually do in practice as they engage in the routine. Each instantiation of the routine is a unique performance.

Ostensive routines may be accessed through peoples’ accounts of the work they do, while observation of repeated rounds of a routine gives insight into the many versions of the performative routine and the relationship between the performative and the ostensive aspects of the routines. When people engage in routines, they select from a repertoire of possible actions (enacting possibilities around which there are explicit or implicit constraints). Different people bring different knowledge, different expertise, different assumptions and different personal and organisational narratives to the enactment of the routine. An understanding of the patterns of possibility and constraints offers insights into wider organisation principles and values, and to an appreciation of complex organisational practices, such as how power circulates and how learning is done. The dynamic interplay between the ostensive and performative routines and the artefacts which are drawn on to support these routines can transform what has traditionally been regarded as mundane and ordinary organisational life (eg, the processing of a repeat prescription) into opportunity for ‘thick description’35 of the nature of organisational life and the wider context within which work is being done.32 36 Continuities and discontinuities in the relationship between ostensive and performative routines may become manifest as puzzles, conflicts, moments of perplexity or tensions.

Recent literature on organisational routines has pointed to the need to pay greater attention to the relational nature of ‘self’ and agency in the performance of routines and in the dynamic processes that address how routines become collective accomplishments with recognisable shared collective characteristics (ie, how the ‘ostensive’ aspect of routines is constituted or brought about).37 38 One approach which offers promise is to locate the study of routines within emerging ‘communication as constitutive of organisation (CCO)’ scholarship,39–42 where communication is itself framed as performance (through conversation and text dialectic). Routines are then framed as communicatively constituted performances, there is greater emphasis placed on performativity, embodiment, dialogic inter-relationships and interest in ‘strings of associations’ that link actors (human and non-human) as routines unfold.43 The nuance of communication gains ground—the emergence of organisational storylines, for example.44–46 This approach aligns with our interest in patient narratives and our orientation to ‘talk about medicines’ as co-constructed accomplishment within the consultation.

Video reflexive ethnography (VRE)

VRE is an innovative approach to quality and safety research in healthcare47–49 which encourages groups of professionals to discuss and reflect on their working practice. In this study, selected video recorded footage of ‘medicines talk’ in our study patients’ consultations will be shown to small groups of professionals across our research sites. VRE offers an opportunity for participants to negotiate shared meanings in their practice, engage with the complexity of their everyday work, and make visible—in new ways—aspects of their practice which have become habituated, taken for granted and ‘invisible’.49 It is a participatory approach in which researchers and practitioners work together to illuminate this complexity and foster dialogue that might not otherwise occur.50 The footage acts as a catalyst, making implicit knowledge explicit through a process of reflection-on-action which renders the work (in this case, the practical work of ‘medicines optimisation’) understandable in new ways and open to new ways of re-imagining practice.51 Importantly, the discussion may go beyond what is visible in the footage, the footage acting as a prompt to inter-professional exchange and peer-led discussion of professional concerns, dilemmas and opportunities. There is opportunity for ‘exnovation’ or innovation from within practice48 and the cultivation of meta-discourses of practice50 which can reframe everyday practices (eg, the ‘medication review’) by drawing out the systemic implications of what specific people know, do and say. By video recording the discussion, this meta-discourse can be teased out and worked with across VRE sessions, in ways which enable practitioners to iteratively reframe their work and negotiate new possibilities for action. Importantly, the collaborative process of co-constructing this meta-discourse in the VRE context may itself be a rehearsal space for new ways of relating and collaborating in the very doing of the work that is under scrutiny.

Participatory co-design

The findings from the research will feed into a process of participatory co-design, working in collaboration with both patients and professionals to design e-learning materials for professional education and patient engagement resources for patients. In this work, we will adapt processes of experience-based co-design52 53 and ‘future groups’,54 the latter being a reinterpretation of focus group methods which uses ideation tools and encourages speculation to imagine alternative approaches to care. We will collaborate with a design researcher to develop our research materials and findings to create bespoke ideation tools and props to facilitate imaginative participation and move towards exploring future alternatives to care prompted by the stories, data and findings from the earlier research.

Integrating analysis across diverse data sets

The project is situated within a broad ‘practice theory’ orientation and adopts a social constructionist orientation. Practice theory encourages an understanding of work as an accomplishment and fosters a curiosity about what is accomplished by whom and how. The organisation (eg, the GP practice or pharmacy) is understood as both the site and the result of work activities and the role of the interpretive researcher is to ‘zoom in’ on the details of particular practices and to ‘zoom out’ to discern the relationships and connections between people, routines, artefacts, spaces and technologies, for example.55 56 As our analysis progresses, we will, in addition, draw on relevant social theory (eg, Burden of Treatment theory57 58) to explicate our findings.

This detailed ethnography will extend our previous research on repeat prescribing in general practice settings in four ways.36 First, the institutional context has changed (one example being the implementation of the Electronic Prescribing Service, another being the incorporation of clinical pharmacists within some GP settings). Second, our research extends beyond general practice into community pharmacy settings and into peoples’ homes and opens up a wider range of vantage points from which to observe the phenomenon. We are focussing our observations around the phenomenon of polypharmacy, recognising that polypharmacy emerges out of an arrangement of practices and is not a discrete entity that can be easily observed without appreciation of a wider social context. Finally, our research includes a commitment to ‘working with’ both health professionals and patients in a process of co-design to produce outputs which we hope will reflect what really matters to staff and patients on the ground.