Award Title: Getting prescription medications right at home, in hospital & hospice: An Activity Theory analysis to improve patient safety and confidence in palliative care
Funder: Marie Curie

Abstract: 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 experienced outcomes do not always match the intended outcomes 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 use of patients’ activity systems as the 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

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?
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

To develop a practice-based model for the multi-step process of prescribing and medication use in palliative care
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
To develop a multi-perspective understanding of 'hot' (attracting attention, viewed as problematic by participants) and 'cold' (not attracting attention from participants, observed by research team) spots in processes and practices of prescribing and medication use for palliative care
To use understanding of practice disturbances to create a learning, analysis and recommendation toolkit identifying targets for innovation and improvement.
 

Methodology

The study uses the conceptual tools of Activity Theory to study effort (work/activity) for prescribing and medication use. This will entail analysing real-life practices during palliative care and how these compare 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 include field notes, audio-recording, and pictorial representations of processes.

Identified disturbances and risks will be explored and categorised (objective 2). Analysis of multiple perspectives will create understanding of actual prescribing and medication use processes (objective 3). This will be mapped to the initial model expanding it into an authentic practice-based model for the whole multi-step process (objective 1) which can be used to identify targets for improvement interventions (objective 4).

Ethical approval will be sought. A patient and public involvement (PPI) co-applicant is involved in designing and delivering the study. A steering group will oversee the study and a PPI engagement group will work with the research team.

Outputs and impact

A theoretically-informed, empirically-evidenced model to identify targets for innovation and improvement in prescribing and medication across palliative care contexts will be produced. Impact will be achieved via:

Publications in high impact peer-reviewed journals
A dissemination event to share and refine findings and develop outputs including toolkits to help patients, carers and professionals with prescribing and medication use
A plain English report freely circulated to policymakers, commissioners, clinicians, researchers and the public
Using findings to design an interventional feasibility study targeting improvement priorities.

Lay Abstract: Background

People with palliative care needs use prescription medications to achieve symptom control. 'Daily hassles' with medications are commonly reported. What happens in 'real life' and the effort required to achieve effective medication management in palliative care is poorly understood.

Aims

The study will collect information from patients, carers and professionals to:

1. Model 'real life' processes underlying medication management including:

Decision-making
Prescribing
Monitoring and supply
Use (Administration)
Stopping/disposal of medications
Moving across healthcare contexts.
 

2. Understand challenges patients and carers face and what they do/do not do to achieve effective medicines management.

3. Understand impact of professional practices on medicines management.

Design and Methods

Three types of context will be identified in order to recruit from home, hospital and hospice. We will develop a visual process model of how using prescription medications should work. We will then observe and explore what really happens and collect information about peoples' experiences of medicines management to develop a 'real life' model.

Activity theory, which can be used to good effect in analysing healthcare processes, is being used to understand what happens, who does what, and what occurs when a patient moves across contexts.

Patient and Public Involvement (PPI)

Consultation with patients, families, friends, carers and healthcare professionals helped develop this proposal.

A PPI co-applicant is part of the team, they will:

Provide an ‘expert-by-experience’ perspective
Assist the research team to engage a wider PPI population
Co-produce study dissemination products and activities.
 

All participants will be invited to a dissemination event and receive the study report.

Benefits and Impact

Understanding processes will help develop effective use of prescription medications.

Recommendations for professionals can improve current practice.

Tools will be created to help patients and carers with medication management.

Further research will test ideas from this study to reduce palliative care medication risks.

Research Activity Codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.2 END OF LIFE CARE
Health Categories: GENERIC HEALTH RELEVANCE;MENTAL HEALTH