Exploring medication safety for frail older people with palliative care needs: Negotiating access and undertaking video reflexive ethnography in primary care settings

Problem

Older Māori and non-Māori requiring palliative care are often prescribed an increasing number of medications placing them at significant risk of harms. The patient safety movement has largely adopted a ‘finding and fixing' approach to these risks. To meet the anticipated growth in the need for palliative care, policy internationally is for GPs to ‘reclaim’ their role from specialist palliative care services charged with ‘deskilling’ them. GPs are expected to build their capacities as generalist experts in palliative care. However there is a paucity of research exploring how medication safety for people with complex needs requiring palliative care is negotiated and enacted from the perspectives of older people and their family/whānau as well as GPs themselves. Further, there is a need to develop research methodologies to better understand complexities in practice whereby participants themselves have the opportunity to engage with matters that are of most significance to them. This work in progress study aims to investigate the feasibility of utilising the innovative methodology video reflexive ethnography (VRE) to explore how medication safety is enacted and negotiated with older Māori and non-Māori with palliative care needs.

Approach

This study applies a strength-based approach utilising VRE. Video Reflexive Ethnography is a collaborative methodology comprising traditional ethnographic methods along with negotiated filming of practice and/or participant accounts of care complimented by reflexive viewing to co-analyse footage. VRE draws upon and recognises the knowledge and understandings of older people themselves and their family/whānau for their own purposes as well as GPs, other clinicians and researchers.

Findings

Conducting VRE within primary care presented several concerns for primary health organizations (PHOs). These included placing additional demands on GP practices. Filming was seen as a burden rather than providing opportunities and associated risks seen to outweigh benefits. Familiar with more conventional forms of research, PHOs questioned how ‘real’ outcomes might be produced and measured.

Consequences

In this paper, we argue that innovative methodologies are needed alongside conventional ones to better understand the complexities of medication safety for older people. By actively disrupting the status quo, VRE is inherently complex and risky producing a number of challenges as well as opportunities. It may, at least in part, be necessary to embrace this risk and complexity to better understand what are often contested perspectives of medication safety in primary care. Paradoxically, by not taking methodological risks there is also a risk that the expert voices of GPs along with patients and family/whānau go unheard. Furthermore by seeking predetermined or fixed outcomes and by steering clear of what we refer to as 'productive vulnerability', how safety matters might be ‘seen’ and done differently are in danger of being overlooked.