Using video reflexive ethnography to explore the use of variable rate intravenous insulin infusions

Diabetes mellitus is a common, serious, and chronic disorder that affects more than 422 million adults globally [1] and is characterised by hyperglycaemia where fasting blood glucose (BG) levels are greater than 7.0 mmol/L (126 mg/dl) [2]. In the UK, the National Diabetes Inpatient Audit (NaDIA) found that the prevalence of hospitalised adult patients with diabetes has steadily risen from 15% in 2011 to 18% in 2017 [3]. Hyperglycaemia is associated with an increased risk of complications and mortality, a longer hospital stay, and a higher admission rate to the intensive care unit [1, 4].

Variable rate intravenous insulin infusions (VRIII) are considered the treatment of choice to achieve optimal BG levels in patients who are unable to eat, who will miss more than one meal, who have severe illness, e.g. sepsis, and where there are special circumstances, e.g. acute coronary syndrome [2]. VRIII is extremely effective at reducing BG levels quickly for hospitalised patients because of the rapid onset of action of the intravenous route of administration, compared to other administration routes. This characteristic, however, carries the risk of causing patient harm because it is not possible to reverse its action if used inappropriately [5]. Therefore, patients treated with VRIIIs need special care in areas such as regular BG measurements, an adjustment of the VRIII rate according to BG readings, and awareness of the appropriate time to transition from using VRIII to subcutaneous insulin if required. The mismanagement of any of these areas is dangerous and can lead to complications such as hypoglycaemia (BG < 4 mmol/L) and ketoacidosis [3].

Patient safety is a vital concern in hospitals and numerous initiatives have been introduced to enhance patient safety when using VRIIIs. Such initiatives included producing practical guidelines for the use of VRIIIs [6], using prefilled, ready-to-administer, injectable medication to mitigate against patient harm due to preparation errors [7], and recommending independent verification for dose calculations, prescription, dispensing, and administration of certain high-alert medications (e.g. VRIII) in order to identify potential errors before medications are administered to patients [8]. The current initiatives are predominantly based on traditional safety approaches that focus on top-down solutions (e.g. standardised policies) introduced into healthcare systems and/or by external experts by learning from specific errors and producing solutions by eliminating errors and filling in any knowledge gaps (Safety-I) [9]. Healthcare systems are considered complex adaptive systems. By definition, complex adaptive systems are systems that include individual agents − doctors, nurses, pharmacists, and patients − who act and interact with each other and with the surrounding environment (e.g. equipment and technology) in dynamic and unpredictable ways that change over time through learning, feedback, and adaptation [10]. Although great efforts have already been made to enhance patient safety while using VRIIIs, the dependence on traditional safety approaches has proved problematic, failing to demonstrate convincing reductions in risk, error or death [11]. For example, a recent study found that despite the use of strategies to maximise venous access, intensive care unit nurses sometimes ran out of sufficient venous access for VRIIIs. Although the use of workarounds such as prioritising infusions and swapping line of infusion was perceived as important to accomplish the task, the study claimed that these workarounds could decrease patient safety by creating new pathways to VRIIIs administration errors [12].

A different way of thinking about safety was introduced, switching the focus from approaches that concentrate on identifying and eliminating errors to more comprehensive approaches that advocate learning from how things go right as well as how they might go wrong (Safety-II) [13]. A relatively new theory called Resilient Health Care (RHC) adopts the Safety-II way of thinking, focusing on understanding how everyday work is actually done rather than how it is assumed to be done [14]. RHC’s proponents argue that performance variability is an integral part of how people and systems deal with expected and unexpected situations, and that their capacity to successfully adapt is what makes a successful system work, enabling good outcomes in spite of problems and challenges [15]. It suggests a shift in focus from learning only from errors to a more complementary perspective of learning from how things go right as well as how things go wrong [16]. One of the important constructs in RHC is the distinction between how everyday work is actually done (‘Work as Done’, WAD) and how work is assumed to be done (‘Work as Imagined’, WAI) [17].

In order to understand how healthcare practitioners work in real life situations (WAD), Iedema et al. used the term ‘exnovation’ (‘innovation from within’) to focus our attention on how healthcare practitioners enact and understand the internal complexity of their clinical work. In contrast to innovation introduced from elsewhere, exnovation is the process of strengthening insight into in situ everyday work, and enabling practitioners to enact on that insight [18]. It is clear that the complexity of care is often taken-for-granted. For that reason, understanding WAD requires an in-depth exploration of everyday work and of the hidden, taken-for-granted clinical work performed by frontline practitioners in situ. Video reflexive ethnography (VRE) is a qualitative methodology involving collaboration between researcher and participants and aims at rendering the complexity of ordinary everyday tasks visible through the videoing of everyday work. VRE has three phases: (a) familiarisation with the work through informal observations; (b) video-recording of everyday work; (c) reflexive meetings in which participants and researcher review the edited footage; and (d) implementing insights and ideas produced during reflexive meetings in practice [18]. Video feedback with those involved in the everyday work enables activation of insights articulated by the practitioners, patients, and researchers collaborating to learn about the work, and to make sense of context (reflexivity). Research shows this process results in participants recommending and initiating designing realistic and realisable solutions to enhance safety and care [18].

The present study is part of a project that has a published protocol [19] with the overarching aim of exploring RHC in the use of VRIII. As far as we know, no previous study has used VRE methodology to explore WAD in the use of VRIII. Therefore, the aim of this study was to understand, by using VRE, how VRIIIs are used in a Vascular Surgery Unit.

Two male patients were recruited and participated in the study. Twenty healthcare practitioners (nurses, senior nurses, pharmacist, specialist registrars, consultants, foundation year one doctors and nurse assistants) working in the Unit provided informed consent before patients were identified and recruited. Twelve healthcare practitioners who were involved in the care of the two patients were approached; of these, 10 healthcare practitioners participated: three nursing assistants, two nurses, three senior nurses, one specialist registrar and one foundation year one doctor. Two declined to participate as they were not trained to use VRIIIs.

In order to conduct the reflexive meetings, the 10 healthcare practitioners involved at the video-recording stage were approached via email and telephone. Three did not reply, two were not able to participate because of work and family issues, leaving five who agreed to take part.

Figure 1 summarises the flow diagram of the recruitment and analysis stages of this study.

This study was the first to explore the use of VRIII in a Vascular Surgery Unit using VRE. The results of this study demonstrated that VRE methodology uncovered the actual and potential hidden complexity in everyday work that encompasses various types of tasks and clarified how it was handled in situ. Engendering healthcare practitioners’ reflexivity helped the researcher to explore how and why some tasks were accomplished in particular ways and to align more closely with the reality of everyday work, the result being a better understanding of WAD while using VRIII. Various methods had previously been used to explore WAD and resilience in healthcare, e.g. field observation, interview, and focus groups [24‐26]. These methods can partially capture an approach to understanding WAD. However, no studies had been conducted to explore WAD in the use of VRIIIs using a VRE methodology in which healthcare practitioners are involved in reviewing, analysing, and reflecting on their work.

To the best of our knowledge, this study is the first to have explored the use VRE to understand how everyday work is done in reference to the use of VRIII. VRE had the utility to explore everyday work and to add depth to understanding how everyday tasks were accomplished. It also generated increased reflexivity in healthcare practitioners, which was a precursor to enhancing their knowledge and insights into how to work in complex systems by proposing practical solutions tailored to their needs.