An ethnographic investigation of communication processes for medication management in hospital spatial environments
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2012
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Melbourne Authors
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Medicine, Dentistry & Health Sciences - Melbourne School of Health Sciences, Department of Nursing
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PhD thesis
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Liu, W. (2012). An ethnographic investigation of communication processes for medication management in hospital spatial environments. PhD thesis, Medicine, Dentistry & Health Sciences - Melbourne School of Health Sciences, Department of Nursing, The University of Melbourne.
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© 2012 Dr. Wei Liu
Abstract
This thesis explores how nurses, doctors and pharmacists communicate with each other and with patients and family members about the management of medications, and how their communication is affected by the space in which clinicians work. It focuses on the interrelationships between communication processes, medication management and hospital spatial environments.
Using a critical ethnographic approach, the medication communication processes among 76 nurses, 31 doctors, one pharmacist, 27 patients and four family members in two medical wards were investigated. Data were collected through participant observations, field interviews, video-recordings, along with individual and group video reflexive interviews. The video method not only captured medication interactions in the context of clinical work, but also enabled clinicians to review and reflect on their own practices. The Medication Communication Model guided the exploration of the complexities of medication communication processes. The critical discourse analytic approach was used to examine social, political and spatial relations embedded in medication communication processes.
The findings demonstrated how clinicians’ medication communication practices were shaped by the ward physical environments, and how clinicians developed communication strategies in response to spatial limitations in the local ward environments. An investigation of formal and informal medication communication modes revealed that power struggles operated between clinicians and patients and among clinicians within specific clinical environments. The findings also demonstrated how medication communication practices were constrained by the organisational discourses of time and efficiency, and how clinicians undertook the practices of scrutinisation and spatial movement to resist institutional dominance and maintain medication safety.
The findings consider the complexities associated with the effects of space and geographic movements on communication processes and medication safety. Effective communication about medications involving patients at the bedside revealed four types of discourse: (1) the professional discourse of medication safety; (2) the management discourse of a structured order on the ward; (3) the organisational discourse of patient recovery and discharge; and (4) the institutional discourse of legal accountability for safe practice. On the other hand, medication decisions made in the private staff station without patient involvement not only led to unintentional clinical consequences, but also had negative social effects on clinician-patient relationships.
Through the process of reflexivity, nurses, doctors and pharmacists were better able to understand the complexities of medication communication processes and recognise their individual knowledge in contributing to medication decisions. As nurses, doctors and pharmacists reflected on the video data, they were able to see the complex power struggles they experienced in their daily practice. They were also able to confront the ways in which their spatial movements within ward spaces affected clinician-patient relationships and clinical outcomes, which opened up possibilities for practice development.
Clinicians should be encouraged to include patients in their daily medication communication practices such as handovers and ward rounds. Increased patient involvement in medication communication practices could also facilitate incorporation of alternative modes of communication such as patients taking up a more autonomous subject position and making inquiries to clinicians about how medications are managed in practice. This thesis also demonstrated the effects of space limitations on medication communication processes. Hospital architects need to consider the potential difficulties confronted by front-line clinicians in their daily work, incorporating their voices into future hospital design.
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critical ethnography, medication communication, power, space, video-recording