Tinker, tailor, deliberate. An ethnographic inquiry into the institutionalized practice of bar-coded medication administration technology by nurses

"Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses

OBJECTIVES

(1) Characterize persistent hazards and inefficiencies in inpatient medication administration; (2) Explore cognitive attributes of medication administration tasks; and (3) Discuss strategies to reduce medication administration technology-related hazards.

MATERIALS AND METHODS

Interviews were conducted with 32 nurses practicing at 2 urban, eastern and western US health systems. Qualitative analysis using inductive and deductive coding included consensus discussion, iterative review, and coding structure revision. We abstracted hazards and inefficiencies through the lens of risks to patient safety and the cognitive perception-action cycle (PAC).

RESULTS

Persistent safety hazards and inefficiencies related to MAT organized around the PAC cycle included: (1) Compatibility constraints create information silos; (2) Missing action cues; (3) Intermittent communication flow between safety monitoring systems and nurses; (4) Occlusion of important alerts by other, less helpful alerts; (5) Dispersed information: Information required for tasks is not collocated; (6) Inconsistent data organization: Mismatch of the display and the user's mental model; (7) Hidden medication administration technologies (MAT) limitations: Inaccurate beliefs about MAT functionality contribute to overreliance on the technology; (8) Software rigidity causes workarounds; (9) Cumbersome dependencies between technology and the physical environment; and (10) Technology breakdowns require adaptive actions.

DISCUSSION

Errors might persist in medication administration despite successful Bar Code Medication Administration and Electronic Medication Administration Record deployment for reducing errors. Opportunities to improve MAT require a deeper understanding of high-level reasoning in medication administration, including control over the information space, collaboration tools, and decision support.

CONCLUSION

Future medication administration technology should consider a deeper understanding of nursing knowledge work for medication administration.

Reconciling imperatives: Clinical guidelines, antibiotic prescribing and the enactment of good care in lower-level health facilities in Tororo, Uganda

Faced with the threat of antimicrobial resistance, health workers are urged to reduce unnecessary prescription of antimicrobials. Clinical guidelines are expected to form the basis of prescribing decisions in practice. Emerging through evaluations of best practice - bundling clinical, technological and economic dimensions - guidelines also create benchmarks through which practice can be assessed with metrics. To understand the relationships between guidelines and practice in the prescribing and dispensing of antibiotics, ethnographic fieldwork was undertaken in lower-level health care facilities in rural Eastern Uganda for 10 months between January and October 2020, involving direct observations during and outside of clinics and interviews with staff. In a context of scarcity, where 'care' is characterised by delivery of medicines, and is constituted beyond algorithmic outputs, we observed that clinical practice was shaped by availability of resources, and professional and patient expectations, as much as by the clinical guidelines. For stewardship to care for patients as well as for medicines, a better understanding of clinical practice and expectations of care is required in relation to and beyond clinical guidelines.

Ethnographic research as an evolving method for supporting healthcare improvement skills: a scoping review

BACKGROUND

The relationship between ethnography and healthcare improvement has been the subject of methodological concern. We conducted a scoping review of ethnographic literature on healthcare improvement topics, with two aims: (1) to describe current ethnographic methods and practices in healthcare improvement research and (2) to consider how these may affect habit and skill formation in the service of healthcare improvement.

METHODS

We used a scoping review methodology drawing on Arksey and O'Malley's methods and more recent guidance. We systematically searched electronic databases including Medline, PsychINFO, EMBASE and CINAHL for papers published between April 2013 - April 2018, with an update in September 2019. Information about study aims, methodology and recommendations for improvement were extracted. We used a theoretical framework outlining the habits and skills required for healthcare improvement to consider how ethnographic research may foster improvement skills.

RESULTS

We included 283 studies covering a wide range of healthcare topics and methods. Ethnography was commonly used for healthcare improvement research about vulnerable populations, e.g. elderly, psychiatry. Focussed ethnography was a prominent method, using a rapid feedback loop into improvement through focus and insider status. Ethnographic approaches such as the use of theory and focus on every day practices can foster improvement skills and habits such as creativity, learning and systems thinking.

CONCLUSIONS

We have identified that a variety of ethnographic approaches can be relevant to improvement. The skills and habits we identified may help ethnographers reflect on their approaches in planning healthcare improvement studies and guide peer-review in this field. An important area of future research will be to understand how ethnographic findings are received by decision-makers.

Knowing antmicrobial resistance in practice: a multi-country qualitative study with human and animal healthcare professionals

Background: Antimicrobial resistance (AMR) is a growing global problem. Raising awareness is central to global and national action plans to address AMR in human and livestock sectors. Evidence on the best ways to reduce antibiotic use, and the impact of awareness raising activities is mixed. This paucity of evidence is acute in Low-Middle-Income Country (LMIC) settings, where healthcare professionals who prescribe and dispense antimicrobial medicines are often assumed to have limited awareness of AMR and limited knowledge of the optimum use of antimicrobials. Objectives: This research aimed to explore AMR awareness among human and animal healthcare professionals and the contextual issues influencing the relationship between awareness and practices of antimicrobial prescribing and dispensing across different LMIC settings. Methods: Qualitative interviews and field observations were undertaken in seven study sites in Ethiopia, India, Nigeria, the Philippines, Sierra Leone and Vietnam. Data included transcripts from interviews with 244 purposively sampled healthcare professionals, analysed for cross-cutting themes. Results: AMR awareness was high among human and animal healthcare professionals. This awareness of AMR did not translate into reduced prescribing and dispensing; rather, it linked to the ready use of next-line antibiotics. Contextual factors that influenced prescribing and dispensing included antibiotic accessibility and affordability; lack of local antibiotic sensitivity information; concerns over hygiene and sanitation; and interaction with medical representatives. Conclusions: The high awareness of AMR in our study populations did not translate into reduced antibiotic prescribing. Contextual factors such as improved infrastructure, information and regulation seem essential for reducing reliance on antibiotics.

HOW BAR CODED MEDICATION ADMINISTRATION TECHNOLOGY AFFECTS THE NURSE-PATIENT RELATIONSHIPS: AN ETHNOGRAPHIC STUDY

OBJECTIVES

This study aims to assess how care is mediated through technology by analyzing the interaction between nurses, patients, and a Bar Coded Medication Administration (BCMA) system. The objective is to explore how patients experience care through medication technology, with the main focus of our observations and interviews on nurses rather than patients.

METHODS

A qualitative ethnographic study was conducted in an orthopedic ward of a Dutch general hospital.

RESULTS

After analyses, the following two themes were discerned: (i) the use of bar code medication technology organizes double institutionalization, and (ii) nurses frequently need to work around the BCMA, as the system is not always supportive of patient needs.

CONCLUSIONS

The results of this study indicate that BCMA is not merely a neutral tool, but an active component within the nurse-patient relationship, as it influences medication administration and profoundly affects patient participation in the care process.