social constructivist analysis of a patient medication record experiment - why a good idea and good...

ORIGINAL PAPERS

Social constructivist analysis of a patient medication record experi - why a good idea and good intentions are not enough LOTTE S. NIZIRGAARD, ELLEN W. S0RENSEN and JANINE M. MORGALL

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Objective -To explain the limited success of a local patient medication record (PMR) experiment in pharmacy practice in Denmark from a social constructivist perspective and to promote a discussion among pharmacy practice researchers of how on-going social constructivist analysis can be used to manage experiments in pharmacy practice. Method - A secondary social constructivist analysis of data collected during and after a local experiment on the development and use of PMRs. Data were analysed using three specific social constructivist concepts. The data consisted of 93 qualitative interviews with elderly medicine users with a PMR, 10 qualitative interviews with representatives from health professionals participating in the experiment, and documentary evidence from a research report. Key findings - Eight relevant social groups were identified in the PMR experiment. The groups attached different meanings to the same PMR, such as: threat; totally useless; important tool for preventing drug-related problems, promoting interdisciplinary co-operation and carrying out pharmaceutical care; unnecessary interference in private affairs; security; good checklist. The relevant social groups also had different opinions about responsibility, duty to inform patients about the PMR, and need for and co-ordination of the PMR. Conclusion -The analysis supports an important social constructivist point, namely, that the outcome of a technological development is not given a pm'ori; rather, it is driven by the interests of various social groups. Ongoing identification and assessment of these social groups is recommended to focus future experiments.

COMPUTERISED patient medication records (PMRs) have been developed and used for many years in countries such as the Netherlands, Unit- ed States, Canada and England.'-4 Although they have been discussed in Denmark for more than 20 years,S PMRs are not part of Danish pharmacy practice. Some patient data on medicine use can be found in pharmacy records, some in general practitioners' medical records, and some in hospital records, but a complete record of a patient's medicine use is not accessible anywhere in the Danish health care system.

The introduction of a Danish computerised PMR system was anticipated and an experiment to develop and test a PMR was launched in Copenhagen in 1990. Local health care practitioners from the primary and secondary health care systems were involved in the experiment.6

The purpose of the experiment was twofold: to assess whether PMRs would rationalise

medicine use in the elderly and whether PMR use would improve co-operation and communication between primary and secondary health care personnel. The experiment was set up in co-operation between health care practitioners (community pharmacists, general practitioners [GI's], hospital physicians and nurses, and district nurses) and a group of researchers. The PMRs con- tained information about the individual medicine user's medication (date supplied, name of drug, dosage, indication and special information), and were updated in five local pharmacies. Patients were given a hand-written version of their PMR which was updated every time they visited the pharmacy. In the pharmacies, the PMRs were kept in a computerised form. Over a period of 16 months, PMRs were handed out to 222 medicine users over 65 years old, who were then supposed to produce the PMR whenever they had contact with health care personnel.

Department of Social Pharmacy, The Royal Danish School of Pharmacy, Universitetsparken

Copenhagen, Denmark L. S. Nrargaard, PhD (pharm), assistant professor E. W. Ssrensen, MSc( pharm), associate professor J. M. Morgall, PhD, associate professor

2, DK-2100

Correspondence: Dr Nsrgaard [email protected]

Int J Pharm Pract 2000:8:237-46

DECEMBER 2000, THE INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 237

The process and outcome of the experiment was evaluated from 1990-1993 through regis- tration of PMR data, observation and interviews. In 1992, 93 of the 222 elderly people who received a PMR were interviewed, and in 1991 and 1992 10 qualitative research interviews were conducted with representatives of the health care personnel who had participated in the experiment. One of the findings of the evaluation was that the PMRs did not contribute to better co- ordination and co-operation between health care professionals working in the primary and secondary health care systems.6

A PMR is a relatively simple piece of technology. One might expect that it would be easy to develop and implement, at least in theory, and that it would be useful for most health care professionals and medicine users. However, a technology is not just a cultural product, but is itself a producer of culture. How can the limited success of the PMR experiment be explained? Ac- cording to Berg,7 technologies are not introduced solely into a predetermined domain; rather they move the boundaries that already exist. For instance, in this experiment, what is pharmaceutical and what is “non-pharmaceutical”? What is medical and what is “non-medical”? Thus, the PMR used in the experiment was not developed in a vacuum: the technology influenced and “constructed” the health care practitioners, health care practice and medicine users to the same degree that the different health care practices influenced and constructed the PMR. The different groups’ understanding of the same technology thus had a strong influence on the development of the technology.

Social constructivist theories are useful for describing the social processes of technological and societal development and were therefore used as the theoretical framework for this article. The purpose of the article is to explain the limited success of a technological development in pharmacy practice from a social constructivist perspective, and to promote a discussion among pharmacy practice researchers of how on-going social constructivist analysis can be used to manage experiments in pharmacy practice.

The following research questions form the basis for the analysis: Which relevant social groups were identified in the PMR experiment, how did :he groups’ perceptions of the PMR contribute :o the interpretative flexibility of the technology, md how can the interpretative flexibility explain :he result of the experiment?

rheoretical considerations

The basic ideas underlying social construction lave been around for a long time, but the social Oesearchers Berger and Luckmans originally used :he term “social construction” to explain the :onstruction of institutions. Later on the term >roved to be a metaphor for a variety of mean-

ings and approaches. Today, social constructivists write about the construction of epistemo- logies, theories, social objects or things. Social constructivism can consist of an ontological programme focusing on social objects and laborato- ry artifacts, or, for instance, a programme centred on the natural world. The epistemology of social constructivism is as follows: The social reality appears different to people who occupy different positions in a social setting. What we take to be objective knowledge and truth is the result of perspective. Knowledge and truth are created, not discovered intellectually.9 Thus, social constructivists recognise the importance of investigating social influences as (co)-determi- nants of the phenomenon under study. Social constructivists share a basic assumption that knowledge is rooted in a particular time and culture (epistemological relativism).lo For social constructivists there is thus no single view or truth; a range of views can be valid in different ways.

When social constructivist ideas are applied to technology, the interaction between society and technology is considered significant, in contrast to technological deterministic theories, which claim that technologies a priori determine social development. For literature that describes and discusses technological determinism see Berg11 Cronberg,l2 MacKenzie and Wajcman,l3 Misa,l4 Nsrgaard and Morgal1,ls and Smith and Marx.16

A specific branch of social constructivism, the social construction of technology theory (SCOT theory), provides concepts for studying a technological development, and specifically empha- sises that a technological development takes place through the social dynamics of negotiation between different groups.17-23 Various concepts can be used to describe and analyse a technological development from a SCOT perspective, including sociological deconstruction (including relevant social group and interpretative flexibility), sociological construction (including closure and stabilisation), and the explanatory scheme (including technological frame and socio-technical ensemble).

In this article, the development of PMRs will be analysed by three concepts: “relevant social group”, “interpretative flexibility” and “closure.” According to Wiebe Bijker,22 these three elements constitute the central basis, for a social constructivist analysis of a technological development. In addition, there seemed to be a good fit between these theoretical concepts and data collected during and after the PMR experiment. The three concepts used for the analysis are described below, all exemplified by Wiebe Bijker’s own history on the development of the safety bicycle.22

First, an explanation of the concept relevant social group (RSG). A relevant social group com- prises a group of people involved in the development of a specific hardware, a specific system

238 THE INTERNATIONAL JOURNAL OF PHARMACY PRACTICE, DECEMBER 2000

or a special process.19 The members of a relevant social group thus share the same set of meanings associated with a specific technology. For instance, in the 19th century, the bicycle did not have one unambiguous meaning, but was evaluated in various ways by the following relevant social groups: bicycle producers, women cyclists, older men, tourist cyclists and sports cyclists. For British producers, who had originally produced sewing machines, weapons and agricultural machines, bicycle production was the solution to their export problem caused by the Franco-Ger- man war in 1869. One group of users, the sports cyclists, constituted “athletic and well-to-do” young men. These young men of means and courage saw riding a high-wheeled bicycle as a way of showing off and drawing attention to themselves. Just mounting a high-wheeled bicycle was a difficult task, an activity viewed by these men as an athletic pastime. Another relevant social group of users was the women, whose clothing was a distinct impediment to mounting Dr riding a high-wheeled bicycle, and the women (like the relevant social group of older men) faced serious safety problems. In those days, cy- :lists were likely to go head over heels when en- :ountering a small obstacle like a stone. Thus, what was viewed as a challenge for the sports :yclist constituted a risk for other groups of users.

By using relevant social groups to describe the ievelopment of a technology, we can demon- strate the interpretative flexibility of the tech- iology. The interpretative flexibility is the total neaning attributed to the technology by all rel- want social groups. In fact, the meaning is what :onstitUtes the technology for the specific rele- rant social group. As stated by Wiebe Bijker:22 ‘If we want to understand the development of .ethnology as a social process, it is crucial to take .he artifacts as they are viewed by RSGs”. By Iutlining the interpretative flexibility of a devel- >ping technology, the researcher can demon- itrate how a technology is culturally constructed, nterpreted and designed.” In the case of the bi- :ycle, the very same bicycle, the high-wheeled nodel, had the following interpretative flexibili- y: An economic rescue for producers; an athlet- c challenge, “The Macho Bicycle”, for the sports :yclists; an artifact with adjacent dress and safe- y problems, “The Unsafe Bicycle”, for women tnd older men.

An analysis of two related processes, closure tnd stabilisation, can identify the social con- truction of a technology. Closure is achieved vhen conflicting groups reach (or are forced to iccept) a specific outcome, for example, when ,oncluding a dispute about a specific technolo- :y.23 The social meaning and physical attributes )ecome stabilised in a closure process, thus ter- ninating the debate about the purpose of the echnology. Thus when closure sets in, the inter- )retative flexibility of the technology is reduced

to a minimum. When there is a dispute within a relevant social group about the development of a technology, the technology is said to have a low degree of stabilisation. The high-wheeled bicycle with solid rubber tyres is a rare sight in the streets today, so obviously closure was never achieved. What happened instead was that a newly developed low-wheeled bicycle with air- filled tyres gradually gained a decisive advantage over the high-wheeled bicycle. Although they had their opponents, air-filled tyres were supported by most relevant social groups. The much smaller wheels on the low-wheeled bicycle elim- inated the clothing problem for the women cyclists, just as the air-filled tyres made cycling much more comfortable for older male cyclists. The sports cyclists realised that they could com- pete on the basis of time rather than danger, and started running races, where they could still show off and draw attention to themselves. Fi- nally, bicycle producers were able to earn more money since a larger population bought the low- wheeled bikes. The debate over the meaning of technology had terminated and closure had set in.

Material and methods

This article is based on a secondary analysis of data collected during or after the PMR experiment. A secondary analysis is carried out when research materials are used by persons other than those who gathered them and/or for purposes different from the original project objectives.

Ten qualitative interviews with representatives from all five health professional groups taking part in the experiment (community pharmacists, GPs, district nurses, hospital nurses and hospital physicians) were carried out. Interview themes in the first round of interviews (1991) were the need for PMRs, the use of PMRs, co-operation with other health professionals, and their views on important issues for the evaluation of the experiment. Interview themes in the second round of interviews (1992) were project experiences, professional knowledge, assessment of the experiment and suggestions for further development of the experiment. Each interview lasted about one hour and was carried out in the interviewee’s workplace. All interviews were tape- recorded and transcribed by a secretary. One of the authors of this paper carried out all of these interviews.

Ninety-three qualitative interviews were carried out with elderly medicine users who had been given a PMR as part of the experiment. The interviews were carried out in 1992. Each interview lasted about one hour and was carried out in the patient’s home. The interviews were carried out on the basis of a semi-structured interview guide covering the following themes: patient’s view on the PMRs, use of the PMRs, assessment of the experiment (on information,


Table 1: Relevant social groups (health care professionals) and their contribution to the interpretative flexibility of the PMR Relevant social Key words for group’s Need for a PMR? PMR target group PMR content group attitude to PMRs and/or form

General Threat Not in the pharmacy, but All medicine users Updated by GP practitioners Useless in medical practice,

updated in pharmacy

preferably developed by the Association of General Practitioners

Hospital Tool for preventing Yes, as monitoring tool Self-sufficient elderly Medication type, dosage, physicians drug-related problems to prevent drug-related taking more than one indication, beginning and

problems kind of medicine discontinuation of treatment. Large print

Community Co-operation, professional Yes, for drug monitoring “Weak” patient groups, Computerised PMRs pharmacists survival and tool for and as tool for improved such as patients taking Different layers of

carrying out communication and more than two kinds of access to data in PMR pharmaceutical care inter d i s c i p 1 in a r y

co-operation discharged from hospital medicine who are

District nurses Shift in perception Before the experiment: No All medicine users Type of medication, of PMR from After the experiment: Yes, prescription date, unimportant to useful supplementary to the identity of the prescriber, tool in daily work medication overview sheet

in the health journal identity of who controls the medicine On-line system in pharmacy

Hospital nurses Tool important as Yes, joint system as basis Patients taking medicine Large print basis for more ongoing information information of nurses

for oral and written without the involvement

onfidentiality, etc), and patient’s view on and uggestions for the health care professions in xms of how PMRs might help with medicine- nd illness-related problems. Sixteen males and ‘7 females were interviewed. One interviewee ras aged between 60 and 70 years, 11 intervie- lees were aged between 71 and 80 years, 59 in- :rviewees were aged between 81 and 90 years, nd 22 interviewees were aged 91 years or old- r. Seven researchers (among them two of the au- iors of this article) carried out the interviews. Lfter each interview the interviewer wrote down er impression of the interview, including the el- erly medicine user’s need for a PMR, satisfac- on with the service, etc. The data presented in this paper are based on re-analysis of interview data collected for a re- :arch report by Ssrensen, Morgall and rskjaer.6 This report contains a description of ie PMR experiment, including observations, iinutes from meetings held during the experi- lent and an analysis of all interviews. The data provided access to a large amount of

nportant historical material on the PMR ex- eriment. All data were analysed using the three xial constructivist concepts: relevant social coups, interpretative flexibility and closure. The social constructivist analysis consisted of

ie following, on the basis of interview data and ata from the evaluation report.6 The relevant xial groups were identified by the meaning they ttached to the PMR. Persons or groups with similar opinions on the

MRs were placed in the same relevant social

group (Tables 1 and 2). The groups with different views on PMRs (the interpretative flexibility) were mapped in Table 1, which shows key words, need for PMRs, target group, and content and form of the PMR, and in Table 2, which shows key words, need for PMRs and attitude towards PMRs. *

Finally, the interpretative flexibility of the PMR was used to describe its degree of closure.

Results

In the following, the sub-elements of interpretative flexibility as described in Table 1 and Table 2 (key words, the need for a PMR, target group for the PMR, content and form of the PMR) will be presented with a focus on the differences between the opinions of the relevant social groups.

Relevant social groups The following relevant social groups were identified in the PMR experiment (Tables 1 and 2): GPs, hospital physicians, community pharmacists, district nurses, hospital nurses, and positive, neutral and negative elder-

*The authors of the SCOT theory, Wiebe Bijker and Trevor Pinch, never described in detail the exact content of interpretative flexibility, mainly because they claim that the focus will differ depending on the specific technology being studied. Thus, the above-men- tioned components of the interpretative flexibility have been chosen on the basis of a specific evaluation of their relevance for the study of Danish PMRs


Table 2: Relevant social groups (medicine users) and their contribution to the interpretative flexibility of the PMR Relevant social Key words for group’s attitude Need for a PMR? Attitude to PMR group Positive elderly Provide security. Good checklist Yes New and interesting option

to PMRs updated in pharmacy

from pharmacy

Positive towards pharmacy, but never really understood purpose of PMR

Neutral elderly “Useful tool” . . . according to the pharmacist

Accepted by group if PMRs help pharmacy personnel

Negative elderly Unnecessary interference in No, PMRs of limited or PMR too difficult to usehemember private affairs no use Not enough information about PMR

PMR not updated

y medicine users. A few key words related to the ’MR are listed to characterise each relevant so- ial group.

nterpretative flexibility Key words - The atti- ude of the GPs can be characterised by the vords: PMR data from the pharmacy - threat- ‘wing and useless. Though represented and active n the experiment project group, the group of 2 s never wholeheartedly supported the experi- nent, and for them PMR technology could be la- lelled “a threat.” By taking on the responsibility or providing information about and developing he PMRs, pharmacists and other groups of iealth care personnel were seen as prying into he GP’s prescription process. For GPs as a cen- ral profession, an obligatory point of passaget n handling drugs was at stake.

The attitude of hospital physicians can be haracterised by the words: PMR data - a tool or preventing drug-related problems. Hospital lhysicians lack complete data on patient nedicine use, and viewed PMRs as a unique ource of this information. Although the health mrnal in the hospital contains a sort of PMR (a iedication overview sheet), the hospital staff till need further information on the patient’s iedication, since data in the medication lverview sheet are not complete. Hospital physi- ians were thus far more positive about the ecords than the GPs, mainly because the records id not constitute a threat to their area of esponsibility. However, remaining true to their ackground and their professional affiliation rith the GPs, the hospital physicians were criti- a1 of the notion that other groups of health care ersonnel would control the PMRs without in- olving the GP. In their view, GPs simply had to e involved in keeping the records up to date. The attitude of the community pharmacists

an be characterised by the words: PMRs - a asis for co-operation, professional survival and tool for pharmaceutical care. The PMR served

:Vera1 functions for this group. It constituted an nportant tool for pharmacists to expand their

kcording to the constructivists Law and Callon,24 ‘e are dealing with an obligatory point of passage ,hen a single locus shapes and mobilises a local net- rork and controls all transactions between the local nd global network

future work in pharmaceutical care. The PMR was also seen as an important tool for co-oper- ating with other health care professionals, an issue that seemed pivotal for the members of this group.

The attitude of the district nurses can be characterised by the words: PMRs - from an unimportant to a useful tool in daily work. At the beginning of the experiment, the district nurses were negative towards the PMR, but at the end of the experiment their scepticism had turned to optimism. The district nurses’ most important role was to observe the patient and administer medicine, and a computer-based medication record to which the district nurse had access would be very useful for that particular purpose.

The attitude of the hospital nurses can be characterised by the words: PMRs - a basis for more ongoing information to the medicine user. The hospital nurses were very positive about a joint PMR system, but emphasised the importance of constantly explaining the purpose of the PMR to the elderly medicine user, in oral and written form. They suggested that the PMR information be supplemented by information from video- tapes. The group was in daily contact with the elderly medicine users, and therefore knew how important it was that the patient had understood all the information about the PMR. In addition, the hospital nurses hoped that the PMR would make patients more self-sufficient and thus less dependent on the district nurses.

Elderly medicine users themselves can be di- vided into three different relevant social groups: positive, neutral and negative medicine users.

Positive elderly medicine users - Key words: Yes to PMRs. Seventy-five out of 93 interviewed elderly people found that a PMR might be a useful tool in their future management of medicines6 This group saw PMRs as a new and interesting option from the pharmacy. It provided security for the medicine user and served as a good checklist for both health care personnel and patient.

“Nice to have an overview of the medication when you can’t keep track of it yourself.”

“ I t [the PMR] was useful to have when I had to go to hospital. ”


Table 3: Three types of relevant social groups Negative relevant social groups

General practitioners Hospital physicians

NeutraVmixed relevant social groups Positive relevant social groups

Community pharmacists District nurses District nurses

I The negative elderly The neutral elderly Hospital nurses The positive elderly

‘‘ . . . a guarantee that I get the right treatment.”

Neutral elderly medicine users - Key words: PMRs? Maybe. This group never really‘ understood the purpose of the PMR or they just did not care much about it. It is difficult to say any- thing precise about the size of this group, but an indicator could be interpreted from the fact that 13 per cent of the interviewed elderly who were not exactly negative towards the PMR had for- gotten all about the PMR, although they had agreed to take part in the experiment.6 They felt that the pharmacy had either forced the medication record on them or that by accepting the PMR they were simply obeying pharmacy “or- ders.” Several members of this relevant social group talked about doing the pharmacy “a favour.”

“The chemist said there weren’t very many in the project, so wouldn’t I like to try?”

“I thought the medication record was some- thing 1 had to have.”

“I was too polite to say no, even though I knew I wouldn’t need the medication record.”

Negative elderly medicine users - Key words: No to PMRs. This group considered PMRs an unnecessary interference in private affairs. They did not know what to do with the PMR or why health care personnel were supposed to use the technology. Members of this group felt unin- formed about the PMR. Again it is difficult to predict the size of the group, but a mid-term report of the PMR experiment showed that after the first six months only 36 elderly medicine users had opted to participate in the experiment, a possible indication that the negative group was relatively large.6

By the end of the experiment in November, 1992, as many as 58 (62 per cent) of the interviewed elderly users found that the PMR had been of no use, and 20 per cent thought that a PMR would never turn into a useful tool for managing drug intake.6

“I don’t need it [the PMR] because my doctor already knows what medication I’m on.”

“I haven’t been given enough information ibout what the medication record is going to be used for.”

“The chemist didn’t ask for the record every time and didn’t really explain why it was important.”

The need for a PMR By the end of the experiment in 1992 some of the relevant social groups involved in the PMR experiment agreed that there was a need for some sort of joint PMR system for drug monitoring and co-operation between the different groups of health care personnel. As can be seen from Table 3, the three exceptions from this agreement were the GPs, the negative elderly users and, to some extent, the district nurses.

The group of negative elderly users includes those who were informed about the PMR but re- fused to participate, as well as those who participated in the experiment but evaluated it negatively. They felt that they were not given enough information about the potential useful- ness of the PMR, did not know they were supposed to show the PMR to other health care personnel, were annoyed that the data in the PMR had not been updated and/or forgot to use the PMR. Further development of the PMRs would presumably only win limited support from this group.

The other negative group was the GPs, who were convinced that having PMRs controlled by other personnel groups was a bad idea:

“Let me make myself quite clear: I don’t think the system should be developed any further. I believe that as all doctors have a PC and can see immediately whether a certain medication is suitable for the patient, they can give the patient an updated list of the medication after each consul- tation.”

The GPs were much more in favour of developing PMRs in a new project started by the As- sociation of General Practitioners. In this project, hospitals were to transfer data electronically to GPs, including the patient’s medication data. The GPs also dissociated themselves from the PMR experiment by talking about “you” instead of “us”:

“It [administration of medication information] can’t be done efficiently the way you are doing it in the experimental project.”

Given how negative the GPs were towards the whole PMR experiment, one might ask why they participated in the first place. One explanation is


that they may have wanted to keep an eye on the experiment, under the pretext of interest in its cost-effectiveness:

“The most important finding will probably be the cost of running it [the project] via the pharmacies. Then perhaps we can work out whether it would be cheaper to run the process from the GPs’ computers, which I believe all GPs will have in the very near future. ”

The district nurses constitute another relevant social group originally negative towards the PMR experiment. During the experiment, however, they changed their minds about the need for the PMR. Initially, the district nurses’ viewed the medication record as a tool that might be useful for other health care personnel, but not for themselves:

“I still find it hard to see where we come into the picture [the experiment]. ’’

The district nurses used their own medication cards as part of the patient’s general medical file and thought that running PMRs from the pharmacy would only complicate the medication administration procedure. However, they gradually realised that they too might benefit from the PMR. For example, electronic access to PMR data via the pharmacies’ on-line system would better equip the district nurses to administer medicine to the elderly. In addition, an electronic PMR would improve their relations with GPs, a relationship the district nurses labelled as rather “difficult.”

Target group The relevant social groups influ- encing the experiment described the target group for PMRs very differently. The hospital nurses believed they would be useful for administering medicine to patients who had no contact with nurses, and the community pharmacists recommended PMRs for “weaker” patient groups, such as patients recently discharged from hospital.

Community pharmacists wanted PMRs and drug monitoring aimed at patient groups who had problems with their medication (or whom the pharmacists expected to have problems). The pharmacists saw themselves as a sort of “watch- dog” concerning medication for elderly people:

“The whole problem with elderly people is whether they actually take the medicine they need - that’s hard for us to say, but we have cases every day where we feel things are not going as the G P and other health care personnel in- tended.”

a1 medication problems, although the pharmacists participating in the experiment had only discovered a few drug-related problems when checking the PMRs. This really annoyed the pharmacists: the PMR experiment seemed only to have reached elderly users who functioned well and had relatively few drug-related problems.

The GPs and district nurses had another view of the target group for PMRs. They believed that a PMR should be kept on each patient and that these computerised records would be a useful daily checklist for the GP and the district nurses. Using PMR data as a way of picking up drug- related problems was not a major issue for these two groups.

Content and form of the PMR The group of GPs again distinguished itself from the other relevant social groups, this time in regard to the content and form of the PMRs. By the end of the experiment, all other relevant social groups of health care personnel agreed that some sort of joint computer-based PMR system was needed, but the GPs still thought they were the only profession who should keep PMR data up to date.

Most relevant social groups in the experiment, especially the hospital physicians and district nurses, had a host of ideas for the content and form of future PMRs, such as type of medication, dosage, indication, identity of the prescriber, beginning and discontinuation of treatment, and large lettering/ print on hand- written and computer-based PMRs.

The community pharmacists emphasised the need for a PMR system with access to different layers of information. For example, they wanted access to medication data, whereas they considered the GPs as the only profession that should have access to all data on the patient.

No closure As the above analysis of the PMR experiment shows, the same PMR, objectively speaking, gave rise to very different meanings (both in terms of use, target group, professions responsible, etc) depending on the relevant social group.

The relevant social groups involved in the experiment had different opinions on responsibility, duty to inform patients about the PMR, and need for and co-ordination of the PMR. In social constructivist terms, the PMR was thus subject to a large degree of interpretative flexibility, and no closure occurred - or was even within reach - during the experimental period. As a conse- quence, the PMR experiment was not continued beyond the initial period.

Discussion

The pharmacists were convinced that elderly medicine users, especially those recently discharged from hospital, were experiencing sever-

Although the original data on which this paper is based were not collected with specific social constructivist theoretical concepts in mind, to a

DECEMBER 2000, THE INTERNATTONAL JOURNAL OF PHARMACY PRACTICE 243

great extent the data proved suitable for such analysis. One disadvantage, however, was that the secondary data did not provide adequate material on what probably should be considered a relevant social group: the group of researchers participating in the PMR experiment. This group is therefore not represented in the results. In addition, the SCOT approach does not provide the researcher with tools for determining the size of a relevant social group. The exact size of a relevant social group can only be determined if the researcher carried out interviews with all members of the group. Despite these problems, we still consider the social constructivist approach useful for studying the social processes of a technological development.

The PMR experiment uncovered several diffi- culties that arise when different professional groups are required to work together to agree on a technological development. The main problem was the boundaries between the different professional areas, especially between the community pharmacists and the GPs. It should be recognised that restricted access and a protected body of knowledge are important to any profession, and this also applies to the health professionals involved in the PMR experiment. As Friedson25 stated, medicine in particular can be seen as a typical example of this phenomenon, in that it seeks to maintain extended influence. Concerns about professional survival were evi- dent in the Danish PMR experiment. Pharma- cists were especially keen to prove their worth and find new roles in pharmaceutical care through the use of PMRs. The Danish pharmacy monopoly on drug sale was a topic of heated discussion in the 1990s and the discussion con- tinues. New research from another Nordic coun- try, Iceland, has shown how the Icelandic pharmacy profession lost its monopoly almost overnight due to liberalisation.26 The Danish pharmacy monopoly on drug sale is no more “se- cure” than the Icelandic, and groups in Denmark thus take a keen interest in what happened in Ice- land when the regulation of drug sale was liber- alised. The PMRs were thus seen by community pharmacists as part of the key to professional survival.

The study outlined the interpretative flexibility of the Danish local PMR and we have demon- strated how the PMR technology was socially constructed and interpreted. We have attempted to show how a specific technological development was influenced by many different factors, such as professional partisan interests, insuffi- cient information for and involvement of patients, lack of support and ignorance about other groups’ wishes and skills. All of these marked the PMR experiment.

How can social constructivist studies contribute to new information in a wider context, to the whole area of pharmacy practice research? What did the SCOT analysis achieve that the

original analyses of data did not? Earlier social constructivist studies in pharmacy practice research carried out by Nsrgaard,27 Tsnnesen28 and Nieman and Nielsen29 focused on describing the history of a system or technology in a pharmacy practice setting. In contrast, this SCOT- based study of the Danish PMR experiment provides important information for implementa- tion of future developments in pharmacy practice, emphasising the need for developments that are even better thought-out and that consider the perspective of other groups. Identifying, diag- nosing and assessing the different relevant social groups or interest groups on an ongoing basis is a recommendation from this research. If, for instance, the interest groups or relevant social groups and the interpretative flexibility of the Danish PMR had been described on an ongoing basis instead of after the experiment, the GPs’ scepticism of the PMR could have been taken into account. The experiment might well have had a rather different outcome in that case.

Analysing interest groups or stakeholders is routine in the analysis of organisations within a political framework.30Jl In that context, stakeholders or interest groups are defined as those in- dividuals or groups that experience or are likely to experience harm or benefits from an organisation’s actions. Stakeholders can maintain for- mal, official or contractual relations and have direct economic impact (primary stakeholders), or can be groups that influence or are affected by the organisation (secondary stakeholders).32 A stakeholder analysis consists of the following steps: Identify key stakeholders, examine the positions of each stakeholder, examine the stakeholder power and capacity for action and assess stakeholder impact.30 Along the same lines, the above SCOT study showed how patients constituted not just one homogeneous group of people, but three groups with different attitudes and opinions about the PMR, meaning that health care personnel ideally should use three different information strategies. The results of the SCOT analysis reveal major differences in the groups’ perspectives on the need, content and target group for the development and use of PMRs in pharmacy practice. These differences constitute important pieces of the PMR puzzle. A good idea and good intentions are simply not enough to guarantee the success of interdisciplinary projects. A certain level of consensus among the participating groups is also necessary, a consensus that was missing from this PMR experiment.

Thus, a SCOT study of any given development in pharmacy practice can raise the awareness of the other groups’ different views and attitudes towards the development. Following and describing the different relevant social groups and their attitudes towards the field of study (the interpretative flexibility) will give project leaders a useful management tool for developing the project further. If one or more relevant social groups


are negative, their resistance should be taken into account and dealt with constructively. The awareness created on the basis of a SCOT analysis can thus become a tool for managing and planning technological intervention projects and experiments, as well as other interdisciplinary co-operation projects. Such an approach might well lead to less problematic and more control- lable developments. Further research is needed to show how the SCOT approach can be used in such a prospective way. This article is only in- tended to describe the first step in this process by mapping the different groups and their different interpretations of the same technology.

Finally, this SCOT study represents a piece of theoretically informed pharmacy practice research. The SCOT theory was used to provide a framework for understanding a development process that involved many relevant social groups. All observations and interpretations have some theoretical assumptions, and the man- ner in which observations are organised, analysed and interpreted determines the findings. Clarifying the theoretical background for the research will enable others to assess its validity and to judge the relevance of the theories for the specific research area.

Conclusion

This article describes how a social constructivist analysis of a PMR experiment might explain the limited success of the experiment. The study supports an important social constructivist point, namely, that the outcome of a technological development is not assumed a priori; rather, professional interests drive it. The study has shown how a technology like the PMR can reorder, change, recreate and redefine the domains of medicine and pharmacy. Thus, the study suggests that conducting more social constructivist analysis in the area of pharmacy practice research is a worthwhile endeavour. The present social constructivist analysis of the PMR can teach us that when trying to explain or even change a process of technological development, we will come to a dead end if we do not take the interpretative flexibility of the specific technology into account.

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Date article received 29.9.99; returned to author for revision 26.1 .OO; accepted for publication 2 7.6.00


social constructivist analysis of a patient medication record experiment - why a good idea and good...

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