Machen, Samantha Jayne; (2021) Assuring medication safety from board to ward – the role of governance and local cultures. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Professional cultures – that is, shared values, attitudes, and behaviours among a professional group – have been identified to play an important role in affecting aspects of patient safety in healthcare. It is argued that these cultures can affirm or contradict an organisation’s safety aims. Despite academic and policy interest, there remains a gap in our understanding of the impact of cultures on the governance and assurance of medication safety. This thesis addresses this gap by conceptualising the role of professional and local ward cultures on the governance and assurance of medication safety across three hospitals within one NHS Foundation Trust. Through an ethnographic lens, this thesis generates detailed insights from structured and unstructured observations (271 hours), interviews (20), and documentary analysis at micro (wards), meso (divisions), and macro (Trust) levels within an organisation to identify the different ‘cultures’ that existed and their relationship with medication safety. The role and influence of cultures, for example professional cultures, was studied at all levels in the organisation. Differing professional ownership existed towards medication safety, giving nurses and pharmacists a more ‘present voice’ than doctors. A focus on inter- and intra-professional working around medication safety identified a fluid conceptualisation of hierarchy across the three study sites. Hierarchical barriers existed but professionals used key tactics to flatten this hierarchy to ensure medication safety. This study also identifies the key role professional cultures play in affecting the implementation of external governance. This role was well acknowledged by senior leaders, yet they identified that they struggled to make changes to medication-specific cultures (e.g. not adhering to a guideline as local norms discouraged it). This study is one of the few to specifically consider the effect of cultures on the governance and assurance of medication safety in an NHS Trust. It also contributes to organisational learning literature by following the operationalisation of two cases of external governance through a complex and multi-layer organisation and identifying the role of cultures at every level of the organisation.

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