Pharmacists process prescriptions, Licensed Practical Nurses (LPNs) move through hallways with their carts, and residents themselves take on the often-overlooked work of managing their own medications. But it’s not just people—technology like the Manrex Pouch Porter system, digital records, and medication carts shape how and when medications flow through the facility.

These everyday details—who does what, how technology is used, and the like—may seem mundane, but they reveal how medication management is organized, how expertise matters, and how residents experience care. My research shows that polypharmacy isn’t just about the number of medications someone takes—it’s about the entire system that enables as well as constrains medication use.

In this post, I take a closer look at the many hands—and technologies—behind medication management in long-term care:

One of the key players in accommodating the flow of medications is the pharmacy. Located within the Long-Term Care Facility (LTCF), Lawton’s pharmacy rents space on the ground floor for the processing of medications, not only for Northwood, but also for seven other LTCFs in the city. In a small space, pharmacy workers are receiving orders, checking orders, communicating with physicians, nurses and others about these orders and other related matters. The facility has a variety of equipment that allows for an output that can match the orders in a speedy manner. Orders received by 15:00 will arrive on the floor the same or next day. Couriers pick up and drop off orders and deliver batches of drugs on an ongoing basis, often accompanied by security companies and their guards.

The flow of medications is carefully managed through a variety of system mechanisms that have been implemented over the past few decades in this LTCF as well as in the broader health care system (Wong and Tscheng Date unknown; Wagner and Rust 2008; Szczepura et al. 2011). For example, the LTCF where I completed my fieldwork uses the Manrex Pouch Porter system.

Manrex’s promotional slogan is “Promoting health by preventing error.” Using the Manrex Pouch Porter system (www.manrex.com), Lawton’s fills, prepares, and counts all medications, and packages them in the Manrex Multi Dose Cellophane Pouch system. Once a week the LPNs from each floor go downstairs to Lawtons to pick up the medications in covered medium-sized plastic storage bins for the floor residents. When the LPN administers the medications to a resident, they are already organized by dose through the Manrex Multi Dose Cellophane Pouch, which remains in the pouch porter system in the medication cart for the week ahead.

Organizations assign roles to ensure work is accomplished in a strategic and efficient manner. In health care, designated scopes of practice help configure who does what, how and when. Current scopes of practice specify that physicians and nurse practitioners can legally prescribe, pharmacists fill prescriptions and do some limited prescribing, while LPNs are involved with the day-to-day managing of the medication side of care, amongst other tasks.

All staff members and residents on the floors are involved in one way or another with medications. Continuing Care Assistants (CCA) do all of the body or personal care work, which includes washing, dressing and helping administer medications during mealtimes. Their scope also allows them to apply prescribed creams to the bodies of residents. The LPNs are doing the daily routine of medication administration as the LPNs move from room to room several times a day with the medication cart, crushing pills, handing out pills or injecting insulin. Some of the medications are measured and handed out in the floor dining space during mealtimes. Each distribution is accounted for in the Medication Administration Record (MAR).

Registered Nurses (RN) assemble information from new and current residents on an ongoing basis, do assessments and engage in various administrative work (collating reports, circulating knowledge, attend meetings, etc). The RN may substitute for the LPN in administering the daily flow of medications during vacation or illness when there is no substitute. However, if a nurse takes over the medication distribution shift it takes much longer, since the nurse has to (re)learn the route, the tempo and preferences of residents, for example, taking meds with yoghurt or water, crushed or halved, etc.

The Pharmacist and Nurse Practitioner (NP) roles are not tied to any specific location as they float between buildings and floors. While the pharmacist is an employee of Lawton’s, the NP is salaried. The pharmacist at this LTCF works 20 hours a week on LTC matters such as bi-annual reviews, taking part in the LTC Pharmaceutical and Therapeutics committee (P&T), and addressing insurance and formulary issues with residents. In addition, his work is stretched out doing additional medication reviewing here and at other LTC facilities. The NP activities include assessments, doing medication reviews as special organizational projects (the anti-psychotic project, for example), writing prescriptions, educational activities, administrative responsibilities (for example the P&T committee), and functioning as a backup resource to nurses, LPNs and physicians. These roving HCPs engage with the floor staff, and are seen as authoritative problem solvers.

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Physicians attend to the medical needs of the residents through weekly organized visits called Doctor Day. Through a provincial program called Care by Design, these physicians have agreed to be the designated doctor for one or multiple floors and to direct the care of the residents and accept an on-call schedule.

The daily care, however, is unquestionably in the hands of the RNs, LPNs and CCAs. Physicians are designated to lead several project-related activities such as filling out the Comprehensive Geriatric Assessment form (CGA), the bi-annual medication review, etc and use their pens and ink to sign off and contribute to the flowing stream of medications. They are self-employed and bill the provincial medicare plan in a piece-meal way.

Finally, residents have significant work and responsibility around their own medical states and burden of treatment. Medications featured as a consequential topic for many of the residents I talked with. The daily work involved by the residents seems largely invisible and unacknowledged (Strauss 1997). As a brief example, I discovered that resident Mrs. J. carefully collected and tended to the discarded MARs so she could keep track of her 20 plus medications, while resident Mr. L. told me that every day he carefully observes and counts his ten morning medications:

"I line them up by shape, size and colour so I know what I am taking. One day other pills showed up and I asked [name of LPN] “what is going on, guys?” Well, apparently the doctor increased this one drug and took another away. Whatever! I have faith in them (resident interview #8).

There’s a management cliché that says, “Culture eats strategy for breakfast.” Spend enough time in a long-term care facility and you see its clinical cousin: Routine eats ideals for lunch.

By “ideals,” I mean the lofty visions we put and see in policy statements across all organizations and staff training slides: shared decision-making, patient-centered care, active participation. These are valuable aspirations. But on the ground, they meet the friction of the everyday—shift changes, med pass schedules, missing paperwork, staff absences. And in those spaces where decisions actually get made, these ideals often morph into something else: pragmatic adaptations to fit the day’s constraints.

One example is the repetitive character of how Doctor Day unfolds on the various floors. It’s a fixed point in the week when a physician, nurse, and sometimes others gather in the nurses’ room to review medication charts, discuss symptoms, and make changes. The nurses’ room itself is locked behind a keypad—a small but important detail. This is a staff-only space, the backstage of care. And here, in the hum of conversation, the resident whose medications are under discussion is often not there in person.

This absence is not necessarily the result of neglect. It is built into the architecture, the timetable, and the habits of the place. The resident is present, but through other means—paper, memory, and conversation. This is what I call the mediated resident.

Routine eats ideals for lunch.

The Mediated Resident

In cases I’ve written about before—Ativan and Teva—the resident’s presence in the decision-making process was entirely mediated. Their story came into the room through chart entries, verbal reports from care aides, and the recollections of staff who had interacted with them days or weeks earlier.

These fragments were treated as sufficient to act upon. A nurse might say, “She’s been more settled since last week,” referring to an interaction in the hallway. A care aide’s note about increased confusion might prompt a dose adjustment. The resident’s own voice—the kind of direct, unfiltered account that patient-centered care advocates call for—was missing.

One moment stands out. A nurse, describing what she believed were the resident’s withdrawal symptoms, saying, “I had these spells.” It was a bodily act of empathy, a merging of her own sensory memory with the imagined experience of the resident. The substitution was powerful—it conveyed urgency and familiarity—but it was still a substitution.

In these conversations, the resident becomes an assemblage of traces: the MAR (Medication Administration Record), a lab report, an anecdote from a hallway encounter. None of these pieces are false, but together they form a composite that is partial, stitched together to be actionable in the moment.

The resident is there—but mostly as an assemblage of paper, memory, and mimicry.

Substitution and Stand-Ins

The stand-ins are not only verbal or gestural—they are also material. The MAR, for example, is a portable, trusted object. It is an authoritative proxy for the resident’s medication history, daily dosing, and recent changes. Staff move it from desk to desk, passing it between hands, consulting it as if it were the resident’s own testimony.

Lab results, printed or pulled up on a computer screen, add another layer. They might confirm a suspected side effect or push the team toward a medication change. In either case, the lab value stands in for the resident’s lived state.

Even the memory of a past event—“remember how she reacted to that antibiotic last year?”—becomes part of the composite. These pieces are mobilised in the room as though they are equivalent to direct presence.

This method of knowing is not careless. It is careful within the constraints of time and space. But it is also revealing: in long-term care, to “know” a resident often means to assemble a usable profile from fragments. It is a craft of patchwork knowledge.

The MAR is more than a chart—it’s a portable and the current most accurate medication version of the resident.

The Spatial Politics of Decision-Making

The nurses’ room is more than just a physical location. It is an access-controlled zone that shapes the boundaries of participation. The keypad on the door is not simply a privacy measure—it enforces a distinction between those who are inside the decision-making process and those who are outside it.

Once inside, the talk is different. Staff speak in shorthand, surmise freely, and sometimes joke. It’s the kind of conversation that doesn’t happen in hallways or at bedside. The resident is present in these conversations only through the proxies already mentioned.

The fact that decisions are made here, rather than in a resident’s room or in a shared space, has consequences. It reinforces the idea that the work of deciding is backstage work—something to be completed and then delivered as a finished product to the resident. When the decision emerges “onstage” in the form of a pill cup or a new order in the MAR, the process that led to it is invisible.

This spatial arrangement is efficient in some ways—it keeps discussions private, allows for quick reference to charts and forms—but it also means that residents are rarely in the position to influence the discussion as it unfolds.

Time, Displaced

Many medication discussions are temporally displaced. The symptoms under review may have occurred weeks earlier; the lab results might be from last week; the most recent verbal report could be from yesterday’s shift. The decision being made is therefore about a version of the resident that is already slightly out of date.

This time lag is not unusual in institutional life. Records take time to compile; shifts change; not all staff work every day. But it has a particular effect in long-term care: even if the intent is to respond to a resident’s current needs, the decision is often shaped by the echoes of their recent past.

When these temporal displacements align—when a lab result matches a verbal report and a chart entry—they can create a strong case for action. But when they don’t, staff must decide which fragment to trust most. And that decision, too, is shaped by habit, hierarchy, and personal judgment.

The “As-If” Resident

Sometimes, staff bridge the gap by speaking in the resident’s imagined voice. “She’d say no to that,” someone might remark. Or, “He wouldn’t like the side effects.” This practice is more than a convenience—it’s a way of keeping the resident “in the room” without actually bringing them in.

It’s also a form of advocacy. By voicing what they believe the resident would want, staff aim to preserve a sense of agency. But it’s agency by proxy. And like all proxies, it depends on how well the stand-in matches the real person’s views and experiences.

These “as-if” moments are pragmatic. They allow the conversation to move forward without rearranging the physical or temporal setup of the meeting. But they also highlight how unusual it would be, in this setting, to have the actual resident weigh in directly.

Affect in the Absence

Affective language and gestures weave through these conversations. “She’s been doing so well lately.” “He’s been a bit off.” These impressions, though informal, can carry as much weight as lab values. They are treated as legitimate indicators of how a resident is doing.

The nurse’s ‘spells’ in the Ativan case is one example of affect crossing into technical talk. It’s a way of collapsing the gap between the resident’s absent body and the decision-maker’s present one.

Emotions circulate alongside data points. They may not be officially recorded, but they are part of the decision-making economy—powerful, persuasive, and woven into the institutional rhythm.

Polypharmacy as a Collective Accomplishment

These observations point to a larger truth: polypharmacy in long-term care is a collective accomplishment. No single person makes the decision. It emerges from the interplay of nurses, pharmacists, care aides, labs, forms, schedules, delivery systems—and the resident, whose presence is refracted through all these intermediaries.

The absence of the resident from the room is not an oversight. It is an outcome of how the system is designed to work. Knowing without being with is not an accident; it’s a feature of the organizational rhythm.

Routine eats ideals for lunch

It’s a quiet truth of long-term care—the one that rarely makes it into policy documents or conference keynotes. In here, the cycle holds — routine eats ideals for lunch every single day. Shifts, med passes, and scheduled reviews pull every decision and conversation into their rhythm. The structure doesn’t just shape what’s possible; it shapes what’s thinkable.

If we want to understand polypharmacy as it actually happens, we have to look closely at the patterns of mediated presence, substitution, and temporal displacement. These patterns don’t reveal individual failings; they expose the deeper logics embedded in the system.

The challenge, then, is not simply to call for more direct resident involvement. It’s to reimagine the spatial, temporal, and procedural structures that make that involvement so rare in the first place. Without changing the shape of the table—who sits at it, where it’s placed, and when it’s set—the mediated resident will remain the norm.

Every week, for several hours, a physician visits each floor of the long-term care facility. Staff refer to it simply as Doctor Day. On the surface, it’s a practical arrangement: the physician responds to urgent concerns, signs forms, and makes decisions about medication. But beneath that, Doctor Day is a complex choreography—an encounter shaped by relationships, paperwork, stories, memories, silences, and the material infrastructure of care.

One of the central tasks during Doctor Day is the completion of the bi-annual medication review form—a routine requirement that keeps the flow of medications legally and practically intact. But this task is more than administrative. As one physician put it, the bi-annual is also a moment to “dig a little deeper”—to pause, however briefly, and reflect on what the resident is taking, why, and whether anything should change. These forms create an opening—a narrow one—for reconsideration amidst the flow.

Why is this important? These scenes might seem like small moments, but they reveal a lot. They show how medication decisions actually happen—not in abstract policy discussions or prescribing guidelines, but in the middle of paperwork, habits, jokes, hierarchy, professional and institutional routines. This is how polypharmacy is made real, and why it’s so hard to undo.

What follows are two close-up vignettes—Ativan and Teva—each capturing how medication decisions are made in the everyday context of Doctor Day. These scenes are followed by a reflection on what they reveal about how polypharmacy is sustained, negotiated, and occasionally unsettled in long-term care.

Image of BIANNUAL form (De-identified)

Vignette 1: Ativan

[Begin Vignette 1]

[On the table several binders are open and a small stack of bi-annuals]

[doctor touches and reads the bi-annual form and then moves her body and eyes towards the maroon binder]

Doctor: OK, how about [first name of resident], how are her bowels?

[the LPN is trying to answer a question from the nurse about who is on call and is writing a note on a piece of paper and is finishing giving medications to a resident who is standing by the door]

Doctor: Are they ok?

[Doctor slightly turns her face to CCA in the room and repeats the question about B's bowels]

CCA is about to say something and then the LPN speaks:

LPN: Her bowels.... it's hard to say, it's hit and miss. If she misses a bowel movement then [unable to capture few words] 9 out of 10 times her bowels won't have moved. You can go back and follow it.

Doctor: Oh really...

LPN: So if she is exploding I won't give the lax-a-day for a bit …

Doctor: So but she usually goes?

LPN: She'll go if you put her on the toilet. I may have given her a fleet maybe once.

Doctor: Does she get codeine at bedtime?

LPN: Yeah

Doctor: Do you want to keep it at bedtime? Or change it to earlier…19:00?

LPN: They are saying they are having a hard time getting pills in her because she is sleepy.

Doctor: What time is her bedtime? 21:00?

[LPN asks CCA what time resident goes to bed]

CCA: Depends on her day but generally she is in bed by 8 o'clock.

Doctor: Does that mean she is getting her pills or is there a lot of coercion?

LPN: [silence as nurse does not respond]

Doctor: Because if she is too drowsy why is she getting this pill?

[LPN went to adjoining room]

Doctor: So I am looking at the codeine here...

LPN: Uhuh

Doctor: So for the most part she is comfortable. She got the amitriptyline at bedtime. She is drowsy at bedtime...hmmm, codeine only has a 4 hour action. ... Do you want to stop the bedtime? She has an as needed..

LPN: I think you can stop them all and keep the PRNs...cause if we get rid of them completely then her shoulder may flare up again. Remember that shoulder? She uses voltaren as well.

Doctor: So… lorazepam...

LPN: Now, before you mess with her Ativan … you should know she only has one sheet of medications!

Doctor: Ok, how about I not mess with it!

[Doctor has a smile on her face and looks up from the paperwork at the LPN]

LPN: Ok, I have a story to tell you and you'll appreciate it.

Doctor: Yeah [laughs]

LPN: Dr xx (the former physician for the floor) took it [Ativan] from me! We had to have a test to see who was right and who was wrong. He took it from me for two weeks and I had these spells - like 9 out of 14 days. And then he had to give it back to me cause I was constantly calling him.

[LPN laughs uproariously]

Doctor: Yeah…

LPN: It’s such a small dose but hey...

Doctor: Ok…

[It is close to 15:00 shift change and CCAs are charting. There are a total of 6 people in room, pens in hand, everyone is writing something.]

[End of Vignette 1]

Vignette 2: Ativan

[Begin Vignette 2]

Nurse sits next to physician

Doctor asks the nurse questions about Mrs J.

Doctor: About Mrs J, How is her mood?

Nurse: Hmmm, good

Doctor: Very good?

Nurse: Yeah, no worse, no better.

Doctor: Pain is controlled?

Nurse: I would say, yeah.

[Doctor focuses on maroon chart bi-annual and shifts attention between the two]

[nurse talks briefly to CCA about a resident]

Doctor: Sleep is good as well?

Nurse: All she does is sleep.

Doctor: Does she want to eat?

Nurse: Yeah

[all clear code red over the intercom announcement]

Doctor: She isn't really participating in activities, is she?

Nurse: No not really, once in a while she goes out to a music program or something.

[nurse gets up and moves to adjacent space to hand form to person coming into nurses’ room]

[doctor is scribbling in both maroon resident chart and on bi-annual]

Doctor: Was she put on Teva combo by respirologist?

[looks at nurse briefly before looking back at paper work in front of her]

[nurse does not respond]

[doctor taps with fingers on form to bring nurse attention back to the form]

Nurse: No, I think you did.

Doctor: What is Teva?

Nurse: I think it was you who put her on it.

[nurse flips through the resident chart]

Nurse: Yes, you did put her on it. She is doing pretty well.

Doctor: uhuh…

Doctor: Has she seen a respirologist?

[doctor is flipping though maroon chart]

Doctor: I see on March 9th I asked for consult. …. Oh just wait a second. Yes she did.

Nurse: Yeah, but not recently

Doctor: But she is doing well? She is not coughing.

Nurse: She is not complaining.

Doctor: How often does she cough?

Nurse: Well, every morning, but not…

Doctor: Yeah, Ok.

The doctor closes the maroon resident binder, gets up and puts it in alphabetical place with the other maroon resident binders.

[End of Vignette 2]

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What the Ativan and Teva Vignettes Reveal About Polypharmacy

1. Medication Decisions Are Situated, Not Singular

The Ativan and Teva vignettes show that medication decisions in long-term care are not discrete clinical acts. They are situated practices, distributed across people, forms, silences, and timelines. There is no single moment when a physician “decides” in the abstract. Instead, decisions unfold in patterned ways—through conversation, chart-flipping, storytelling, hesitation, negotiation, and ritual.

This is what polypharmacy is—not simply “too many medications,” but an assemblage of small, mostly invisible decisions made possible by institutional routines and infrastructures. It is not accidental; it is made.

2. The Nurses’ Room as a Knowing Location

These scenes unfold in the nurses’ room, a space dense with the material and social resources that make medication decisions possible. It is not a neutral backdrop, but a working infrastructure. It houses binders, forms, digital records, jokes, interruptions, and habitual rhythms. It also enacts a kind of order—a place where the doctor and nurse co-locate to “know” the resident.

Susan Leigh Star, a sociologist whose work I return to often, reminds us that space always reflects priorities. The nurses’ room brings together what matters in the everyday care of residents: the flow of drugs, the accountability of signatures, and the temporal demand of institutional forms. It is where paperwork becomes practice.

3. Forms, Objects, and the Texture of Work

The bi-annual medication review form structures the work of Doctor Day. It is a legally and practically necessary document—if it’s not filled out on time, the flow of medications is disrupted. But it is also an opportunity: a rare, time-boxed moment to “dig a little deeper,” as one physician put it.

The form sets the tempo. The pen moves between the bi-annual and the progress notes. The MAR sheet is consulted to stabilize a memory or verify a dose. These are not mere tools of documentation; they are actors in the practice. They determine what is seen, said, and done—and in what order.

And they do more than guide care; they shape it. The content of care is often determined by what the form requires: continue, stop, or change. The ease of “continue” often outweighs the effort of “stop.”

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4. Power, Hierarchy, and the Ink of the Pen

Despite the cooperative tone, power circulates through the scene in subtle and highly material ways—most visibly through the physician’s pen. Her signature authorizes action. Her initials on the bi-annual form and green progress notes legalize the continuation or cessation of a drug. Her ink is what moves a medication into or out of circulation.

And yet, that power is rarely wielded unilaterally. In the Ativan vignette, we see the nurse intervening decisively. She doesn’t argue outright. Instead, she stages a kind of narrative interruption. As the physician moves toward discussing deprescribing lorazepam, the nurse steps in—not with data or clinical rationale, but with a story. She says: “Before you mess with her Ativan… I have a story to tell you.”

It is not a story about the resident per se. It is a story about her own struggle with a previous physician over the same issue. The narrative is framed as a kind of trial-by-substitution: the doctor took the Ativan away, and she—the LPN—suffered the consequences. She says, “I had these spells,” as though she herself were the patient in withdrawal. The boundary between nurse and resident collapses.

This is not mere humour or dramatic flair. It can be understood as a form of embodied advocacy. The nurse is not just presenting clinical facts; she is re-enacting the resident’s past distress, claiming experiential knowledge that supersedes the chart. She is saying: I lived this. I know what happens when you take it away. Don’t do it again.

She is also doing something institutional: referencing the “one-sheet med list” as an index of acceptable polypharmacy levels. The bi-annual, after all, is a visual artifact; one page = eight medications. Fewer pages means fewer questions. This is another form of persuasion—pointing to legibility and acceptability rather than risk.

In the end, the physician listens. She smiles. She says, “Ok, I won’t mess with it.” The nurse wins—but not through resistance or confrontation. Through storytelling, affect, shared memory, and institutional shorthand. And while the pen still holds the formal power, it is the nurse who shapes the hand that moves it.

5. The Semantic Repertoire of Long-Term Care

Doctor Day operates within a shared semantic field. Staff use shorthand to communicate efficiently: “bowels,” “one-sheet med list,” “Ativan.” These words are not simply clinical—they are contextual, situated in the texture of long-term care.

This language enables care, but it also narrows it. It privileges what is decipherable within the institution. Concerns are framed in terms of dosage, sleepiness, agitation, and participation in activities. This is the vocabulary that gets a response—and the one that gets recorded.

6. Knowing the Resident: Fragmented, Embodied, and Substituted

Across both vignettes, the resident—the person whose medications are being adjusted or renewed—is notably absent. There is no direct consultation that we know of, no negotiation, no moment of shared decision-making with the person most affected. Instead, the resident is talked about, remembered, and approximated through stories, observations, and charts.

Is this absence neglectful or is a feature of institutional life? The resident is made present through documentation, affective recall, and conversational shorthand. In one moment, the nurse even uses her own body to describe the resident’s withdrawal symptoms, saying, “I had these spells,” effectively fusing her memory with the resident’s presumed experience.

But this is a different kind of presence—mediated, constructed, and partial. It highlights a tension at the heart of polypharmacy in LTC: while medications are administered to residents, decisions about them are often made around them.

I will return to this phenomenon in a future post.

7. Why Deprescribing Is So Difficult

In both vignettes, there is space for change—but not much movement. In the Ativan case, deprescribing is considered but politely deferred. In the Teva example, uncertainty around the drug’s origin leads not to removal, but to continuation. Neither drug is stopped.

Is this due to negligence or inattention or due to structure. The path of least resistance is to continue. Deprescribing, by contrast, introduces uncertainty, effort, documentation, and sometimes conflict. It is harder to stop than to maintain.

The bi-annual form may offer an opening, but it is narrow, fast-moving, and deeply embedded in organizational rhythms that perhaps favour the status quo.

Conclusion

What these scenes show is that polypharmacy is not just the presence of many drugs, rather it is an organizational rhythm, it’s a product of how care is organized. It is the result of forms, habits, distributed knowing, space, and partial presence (of patients). It is not just what doctors and other health care workers do, but what systems make possible.

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This post zooms in on one of the most important yet unseen spaces in long-term care: the nurses’ room. It is here that the clinical and administrative work of care comes together, where medications are tracked, forms are signed, and crucial decisions about residents’ health are recorded. My broader goal is to understand how (problematic) polypharmacy unfolds, and the nurses’ room offers a window into the everyday institutional dynamics that make it possible.

Why does this matter? Because polypharmacy in long-term care (and elsewhere) is not just a medical issue—it is also an organizational one. Decisions about medications are made within a system of documentation, delegation, and professional hierarchies that influence what gets prescribed, renewed, or discontinued. To understand how residents come to be on multiple medications—and why deprescribing and other attempts to stem the flow of medications is so difficult—we need to examine where and how these decisions happen. To start, I take you inside the nurses’ room, a small but central space where medication management, staff coordination, and institutional routines intersect to sustain the rhythms of polypharmacy:

During one of my fieldwork visits to the Long-Term Care Facility (LTCF), I take the elevator to one of the residential floors. Given the architectural similarities, it is sometimes hard to remember which floor I am on. I exit the elevator and knock on the nurses’ room for one of my planned observations of Doctor Day, where the physician attends to the needs of the residents on the floor. There is a restricted access key-pad on the nurses’ room and I do not have the code and so one of the CCA’s (continuing care assistant) opens the door for me. Entering the nurses’ room, I notice there is a table, some chairs, and on the built-in desk on the outer edge of the room there is some computer equipment, binders, pieces of paper, and pens. There are several rows of heavy-duty maroon coloured resident binders or charts, the Doctor Book^[1], and preprinted required forms such as the CGA (comprehensive geriatric assessment form) or the Bi-Annual which is a 6 month standard medication renewal form. Looking around the room I notice on the wall a taped legal sized piece of paper with 25 categories of “Standardized Filing Order.”

Categories include assessment, communication, consent and release forms, infection control, medication related forms^[2], monthly forms, education/orientation, scheduling forms, outbreak binder, Doctor Book, and audits. One of the nurses shows me on the computer that there is a directory containing 302 files/forms of organizationally specific policies around areas such as nursing interventions, medication management and administration, staffing and scheduling, and Care by Design policies.

During this one day or morning or afternoon or evening a week, the assigned physician visits the floor. The work of Doctor Day is layered amongst the rhythms of everyday floor life. Daily activities go on as usual. The nurse, LPN and CCAs are juggling the varieties of care work on the floor: doing medpass (administering medications), changing wound dressings, administrative work, personal care work, and the like. Other staff are doing custodial work or prepping and serving food. Residents are also active participants. They are maintaining themselves by eating, sleeping, waiting, readying themselves for personal care work, swallowing drugs, and offering their arm for injections or drawing blood.

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The power of documentation in the nurses’ room is everywhere as the highly accountable work is commonly structured by engaging with forms and text and pens (Smith 2001). The forms tend to be filled out or accomplished through a text-action-text sequence (Campbell and Rankin 2017). These objects shape the time, place and rhythm of the working day and its unfolding tasks. The CCA has a checklist, completes items on it, and rechecks it. The LPN reviews the pouches, 24 hour checks, and then administers the medications. For every drug dispensed she puts a checkmark on the MAR (medication Administration Record) as a sign of accountability.

Accountability is enacted in initials, signatures, and check marks. These are separated by scopes of practice: what you can and can’t do and what you are responsible for; scopes of practice are not, however, rigid. People and objects are always dependent on each other for bits and pieces of information and skills. For example, the chart and the MAR are relatively stable objects, though the MAR is moved around on the floor with great intensity during med pass, and it bridges time and space and can be consulted by staff when in eyeshot.

During the morning or afternoon of Doctor Day different tasks will be accomplished. The floor and the nurses’ room is run by the daily staff. The work that the physician will do produces a ripple of work downstream on the floor and within the organization, to the resident, LPN, RN and the pharmacy. The visit will also help move along some of the floor concerns, such as attending to time-sensitive forms, like bi-annuals, or dealing with specific resident and nurse concerns. Depending on the floor, the needs and capacity of the residents, and the practice preferences of the physicians, and the style of working relationships, the LPN/RN will be involved more or less during Doctor Day. Answering questions from the doctor will be one of many tasks today.

As usual, the RN/LPN shift starts at 7 am and she has been busying herself with responsibilities, ensuring the CCAs are up to date on the latest resident concerns and making sure to get things in order for Doctor Day. She knows that the visit by the physician is time-limited, and she is smoothing the way.

In the nurses’ room, there is a lot of scribbling by the CCAs, as they cross off their daily tasks. There is also a variety of talk. Staff are exchanging information of all types, personal anecdotes about the weekend (a concert attendance, a sports activity) and fragments of information about residents, sometimes clinical, sometimes more personal such as noticing a nice haircut on Gerry, a resident on the floor. Various staff members come in and out of the nurses’ room using the restricted access key-pad, and residents know they are generally not allowed in this room.

In the coming posts, I’ll take a closer look at how the billable Bi-Annual Medication Review Forms are completed—how they do structure decisions, reinforce institutional routines, and ultimately shape the medication regimens of LTC residents.

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^[1] The Dr Book (also known as communication book) has the following nine forms according to “Standardized filing order sheet”: Care by Design on call SBAR, exception status sheet - see MD binder, Nova Scotia Provincial Pharmacare Programs first request for cholinesterase, Nova Scotia Provincial Pharmacare Programs request for renewal of a cholinesterase, nursing concerns, physician follow up, reorder.

^[2] Medication related forms have the following 28 forms: listings of medication storage, MAR sheet (Lawtons), medication administration information, medication coverage agreement, medication discontinued form for pharmacy (yellow), medication new order form for pharmacy (pink), medication reconciliation form, medication reorder form for pharmacy (green), monitoring of new or dosage change in antidepressants, monitoring of new or dosage change in anxiolytics, monitoring of new or dosage change in anxipsychotics [sic], monitoring of new or dosage change in cognitive enhancers, monitoring of new or dosage change in cognitive enhancers, monitoring of new or dosage change in mood stabilizers, narcotic count record, order set for prophylaxis treatment of influenza like illness 2014-15, resident request for product, supplement, and/or other, alternative/ complementary, RN/LPN master signature form for medication administration, routine bowel directive for constipation, routine medical directive, self admin of medication agreement app B, self admin of medication, clinical assess & prescriber, authorization app A, stable dose warfarin, subcutaneous injections rotation form, transform medication application sheet, treatment record, warfarin and INR record.

One way to see these hidden structures in action is by looking closely at the spaces where care happens and the routines that unfold within them. The nurses’ room, for example, is more than just a functional workspace—it actively shapes how care is organized, communicated, and prioritized.

Far from being a neutral space, this kind of everyday infrastructure structure prefigures certain activities while limiting others. It creates the conditions under which work unfolds. In the case of the nurses’ room, its setup—both physical and institutional—determines how care work is organized and prioritized. The objects and the routines embedded in each practice arrangement reflects institutional values and priorities. This post will take you along to what the rhythm of a LTC floor is like.

Within the Long-Term care facility (LTCF) many tasks are enacted in a time-anchored matter. While residents live in the LTCF 24 hours a day, the staff comes in and out, marked by 8- or 12-hour shifts. The nursing shift is between 7:00 and 15:00, while Licensed practical Nurses (LPN’s) are present during all shifts. Residents spend 168 hrs a week (7x24 hours, or all of their time) in the LTCF, while LPNs and nurses upwards of 40 hours and physicians approximately 3 to 4 hours (per floor). Both resident and staff activities are tethered to the institutional routines (or calendaring 24 hours in a day). Eating, too, is time specific (breakfast, lunch, dinner), and a substantial amount, but not all, of the distribution of medications is routinized around meal times, in the dining space or sometimes in the residents’ room. Time specific medications are provided around their earmarked times and PRNs as needed.

Even though all people in this institution have significant medical needs, the preferred term is ‘resident’ not patient. They are called residents because they live in a 24 hours-a-day medicalized home. For nearly all, this institution will be their final home. It is generally accepted that these days residents coming into LTC are ‘older and sicker’. One of government’s goals is to keep ailing people in their own homes longer.

All floors in the LTCF have very similar design and spatial characteristics. Most floors have up to 33 residents with beds in single, double and triple rooms. These rooms are located on the outer edges of the building with various views of the city or the harbour. There are small nooks for doing puzzles or other leisure activities. I notice modest attempts at trying to make it more home-like with plants and art or posters on the wall.

Several central hubs are embedded on each floor and these include the dining room and kitchen area, a TV space or room, a large bathing room, storage spaces, and the nurses’ room. The hallways are wide and the equipment in them, such as wheel chairs, mobile floor lifts, and walkers, reveal something about the fragility and dependency of the residents who live here 24/7.

In upcoming posts, I will explore how work unfolds within these structured spaces. Next,

I’ll take a closer look at the nurses’ room—an often-overlooked space that plays a central role in shaping care.

My research reimagines polypharmacy as an organizational practice, moving beyond the clinical or numerical to expose its deeper roots and implications. At Northwood, polypharmacy isn’t just something that happens; it’s something everyone—residents, healthcare professionals, administrators—is doing. It’s a practice that organizes people, relationships, and routines, and in turn, leaves indelible marks on the institution itself.

Polypharmacy creates a delicate dependency. Residents rely on medications to manage their conditions, while healthcare practitioners depend on the institutional structures—and the medicolegal work of forms and routines—that sustain this flow. But this dependency has a cost. Residents, the most vulnerable players in this system, are largely shut out of decisions about the medications that define their daily lives. Meanwhile, the routines designed to maintain the flow of medications impose a heavy burden of treatment—one that’s as emotional as it is physical.

Through the smallest details—the completion of a bi-annual form, the placement of a medication cart, the conversations between nurses and physicians—it becomes clear how polypharmacy is woven into the organizational fabric. The residential floors hum with activity, a tangled web of humans, objects, forms, and regulations, all working together to keep medications flowing.

Ultimately, my research circles back to one fact: in 2017, 4,927 doses of medication were distributed in a single day at Northwood, across 303 residents (more on this in a separate post). What allows this flow to exist? What structures and routines hold it in place? And what are the consequences for those living and working within its grasp?

What I found was a collective, organizational practice—a deeply embedded, stable arrangement that choreographs the lives of residents and practitioners alike. Polypharmacy isn’t just an element of care at Northwood—it’s a system, a culture, a way of life.

1. Doctor Day, the bi-annual form, and the missing resident

2. The burden of treatment for residents at Northwood

3. Polypharmacy is hard work: solving the medication mystery and handover dilemma

4. How forms shape activities and identities at Northwood

5. Polypharmacy is an organizational practice

My empirical findings demonstrate how medication work or “doing polypharmacy” is accomplished. The work of polypharmacy is relentless and demanding. It is a collective, shared enterprise between the prescribers, residents, other HCPs, medications, and cultural ideas and practices (rules, forms, etc) of what is acceptable at Northwood.

1. Doctor Day, The Bi-Annual Form, and the Missing Resident

In two vignettes, Ativan and Teva, we witness the peculiar yet widely accepted rhythm of Doctor Day, where the nurse and physician orbit the six-month medication review form, a document so vital it dictates the medication flow at Northwood. Within the number-locked nurses’ room, a space where the absent residents are conjured through questions and chart notes, the bi-annual form orchestrates an intricate ritual of knowing. Here, the resident becomes both visible and invisible—a figure reconstructed from fragments of conversation, paperwork, and memory. The physician and the LPN bring the resident to life through their conversations—asking and answering questions, piecing together fragments of information, investigating details, and documenting the absent resident’s story in the charts. The work unfolds in repetitive ways: the physician asks questions and the LPN answers, pens scratching against paper, binders opening and closing, and the urgency to ensure the medications keep flowing.

2. The Burden of Treatment for Northwood Residents

For Northwood’s frail and vulnerable residents, the burden isn’t just their illness—it’s the constant effort to manage the treatments meant to sustain them. These residents are locked in a quiet struggle, caught between the rigidity of institutional care and the messy, embodied reality of living with chronic conditions. One resident confessed, “I line up my pills by shape and color to catch mistakes.” Another voiced their frustration: “I think the doctor decides everything without even seeing me.” This burden of treatment—unseen and unmeasured—demands notice. It calls for a new kind of care, one that prioritizes minimally disruptive medicine, shifting focus from disease to the person enduring its effects.

3. Polypharmacy is Hard Work: Solving the Medication Mystery or Handover Dilemma

In Mrs. J’s Medication Mystery, we see polypharmacy work laid bare: an incomplete hospital form sets off a cascade of repair work spanning hours and multiple organizations. The simple question—“Is she on 26 or 28 medications?”—becomes a sprawling investigation involving nurses, pharmacists, forms, and faxes. The answers are never stable; knowing is a process of reconstruction, a relentless pursuit of fragments scattered across charts, systems, and memories. The work is exhausting, the stakes are high, and yet, the rhythm of polypharmacy demands that it all be done again tomorrow.

4. How Forms Shape Activities and Identities at Northwood

At Northwood, a high accountability institution, forms don’t just record actions; they shape them. Consider the quarterly medication incident review form (the 2026 form below has been replaced in 2019), which categorizes nursing and pharmacy errors but omits prescribing altogether. It’s a subtle exclusion with weighty implications: physicians are untouchable, their actions shielded from feedback loops that others endure. As one nurse put it, “When it comes to physicians, there’s no feedback, no boss.” Forms like these silently reinforce hierarchies, dictate workflows, and even mold the identities of those who use them. They’re not just tools; they’re cultural artifacts, shaping how people think, act, and perceive their place in the system.

5. Polypharmacy is an Organizational Practice

Polypharmacy isn’t a side effect of prescribing, though it is that as well—it’s a living, breathing practice embedded within the institution. It’s an unending cycle of coordination and care, requiring the alignment of people, objects, and routines. From the maroon binders in the nurses’ room to the medication carts rattling down the hall, every element at Northwood is choreographed to keep the flow of drugs uninterrupted. Yet, this practice doesn’t exist without cost. It shapes identities, power dynamics, and the everyday lives of residents and healthcare workers alike. Polypharmacy is not just something Northwood does; it’s something Northwood (and all LTCF’s) is.

But the numbers only tell part of the story. These pills, creams, and injections don’t just flow through bodies—they weave their way through the institution, passing through rooms, hands, systems, and objects, leaving traces on everything and everyone they touch. To make sense of this intricate choreography, I took the numbers as my starting point and followed the flow of medications as they coursed through the corridors and bodies at Northwood.

Real-world research or empirical sociology or ethnography became my lens, a way to capture the daily rhythms of polypharmacy as it unfolded in real time. Over nearly a year, I immersed myself in the life of Northwood, physically shadowing the routines, rituals, and relationships that kept the system running. I sat in nurses’ rooms, observed ‘doctor day,’ followed the anti-psychotic project, lingered in dining rooms, and attended pharmaceutical and therapeutics committee meetings. I shadowed the staff—LPNs, nurses, physicians, and administrators—and asked them questions that cut to the heart of the practice: who and what keeps this medication flow alive? What habits, objects, and decisions sustain it? What are the ripples, both intended and unintended, that follow?

From training sessions to the smallest moments of care, I watched as medications shaped not just the daily work but the identities, power dynamics, and relationships at Northwood. I tracked how objects—charts, binders, pill bottles, even the physical layout of rooms—dictated the flow of work and shaped the people moving through those spaces. Each scene became a microcosm of the larger system, a place where people and objects collaborated, collided, and kept the machinery of polypharmacy humming along.

I brought a practice-based framework to this tangled world (Nicolini 2012; Gherardi 2019), asking not just what happens, but how and why. Northwood revealed itself as a place where the ordinary—like filling out a form or handing a resident their pills—is anything but simple. Every action and interaction is part of a larger pattern, a living, breathing system where medications are both a lifeline and a constant presence shaping life within the institution.

Polypharmacy is, at its core, a troubling paradox. Physician researcher Doron Garfinkel calls it an “iatrogenic epidemic,” even waging a self-proclaimed “War Against Polypharmacy” in academic journals (Garfinkel et al. 2007). On the flip side, a 2013 BMJ article resigns itself to calling polypharmacy a “Necessary Evil” (Wise 2013). What’s not up for debate is the toll it takes. Frail seniors, already at their most vulnerable, are enlisted into an daily regimen of medication management. The tasks are endless—tracking doses, timing their day around pill schedules, navigating the labyrinth of side effects, and trying to pin down the sometimes always-on-the-move floor physician. Even leaving Northwood requires careful calculation, lest the resident misses their next dose. This exhausting cycle, described by some as the “burden of treatment,” has led to urgent calls for “minimally disruptive medicine” (May et al. 2009).

My research steps into this space, not to question whether Resident A should or shouldn’t be taking Medication B, but to examine polypharmacy as a living, breathing practice. At Northwood, polypharmacy is not just a phenomenon but a labor-intensive process, woven into the routines, culture, and organizational dynamics of the institution. Every chart filled, every form faxed, every pill delivered is part of the machinery that sustains this complex system. Polypharmacy is not just something that happens at Northwood—it’s something everyone, from residents to healthcare practitioners, is doing, around the globe. And like all work, it comes with both intended consequences and ripple effects no one ever saw coming.

For some initial references see the reference list.

• A New Lens on Polypharmacy: My work reimagines polypharmacy not as an outcome of prescribing alone but as an organizational practice—one that’s deeply rooted in materiality, structures, routines, and the people who in essence own a collective and situated knowledge.

• An Institutional Phenomenon: At Northwood (and any other LTCF), polypharmacy requires ongoing production and reproduction, with every practitioner, administrator, resident, form, and object contributing to its perpetuation.

The findings reveal a complex web of routines, relationships, and impacts:

1. An Institutional Practice: Polypharmacy is embedded in Northwood’s organizational DNA, part of the routines and rhythms that define its daily life. It’s a way of doing that dictates “how bodies move, objects are handled, and care is understood” (Nicolini, 2012).

2. A Collective Enterprise: Everyone—residents, healthcare professionals, administrators—and everything—forms, objects, architecture—plays a role in sustaining the work of polypharmacy.

3. A Bias Toward More: The structures and routines, like the bi-annual medication review, sometimes seem to be sustaining, not challenging, problematic polypharmacy.

4. Stabilizing Practices: Routines create a sense of order and reliability but also entrench the practice of (problematic) polypharmacy within the institution.

5. Knowing Residents Through Pills: Medication work produces specific ways of “knowing” and caring for residents, sometimes reducing them to what’s written in charts and forms.

6. Power and Conflict: Polypharmacy reveals and reproduces hierarchies—between professionals, between residents and staff—and the inevitable tensions that follow.

7. Structuring Lives and Identities: This type of practice-arrangement shapes how residents and healthcare providers see themselves and each other, defining roles and reinforcing dependency.

8. The Architecture of Control: The organization of people in space—through routines, forms, and places—determines who gets autonomy and who doesn’t, offering or denying residents control over their lives. This isn’t unique to Northwood; these characteristics are hallmarks of any total institution, as Erving Goffman so vividly described.

9. The Burden of Treatment: For residents, the weight of polypharmacy isn’t just about side effects—for some it’s a feeling of exclusion, the uncertainty, the relentless work of managing medications in a system that keeps them on the margins.

10. Forms as Silent Architects: As I demonstrate elsewhere, the 2016 “medication incidents” form—it tells a story of exclusion, where prescribers escape accountability and feedback, shifting responsibility downstream.

Polypharmacy at Northwood is a non-stop, all-encompassing system, not a byproduct of (only) prescribing but a deeply entrenched practice. It organizes life, shapes relationships, and imposes burdens that ripple through the institution, reinforcing power dynamics and cultural norms in ways that are as unsettling as they are revealing.

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Abbreviations

Bi-annual form - 6-month standard medication renewal form

CBD - Care by Design

CCA - continuing care assistant

CGA - comprehensive geriatric assessment form

HCP - health care professional

LPN - licensed practical nurse

LTC-CGA - comprehensive geriatric assessment form

LTCF - long term care facility

MAR - Medication Administration Record

Med Pass - administering medications using medication cart

MOHLTC - Ministry of Health and Long-Term Care

NP - Nurse practitioner

PBS - Practice Based Studies (practice theory)

PRN - medications as needed

P&T Committee - Pharmaceutical and Therapeutics Committee

RN - registered nurse

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This post continues on from the ‘about’ section. This Substack delves into the complexities of polypharmacy, starting with its role in long-term care facilities (LTCFs), where I conducted my Real-World or ethnographic empirical research. In LTCFs, polypharmacy is one of the more ordinary and profound realities of everyday life. This Substack isn't here to rehash the usual finger-wagging about too many prescriptions (though I am interested in the numbers as well) or lay blame at the feet of hardworking healthcare professionals. Instead, it's about peeling back the curtain to reveal how the everyday, seemingly mundane routines of medication work ripple through the lives of residents, care workers, the organizations, and the broader system itself.

Here's the thing, polypharmacy isn't just about the number of pills on a chart or on the medication cart or in the bodies of residents. It's a living, breathing practice, shaped by the messy and very human interactions between people, policies, technologies, and places. My research, set in the intimate corridors of a Canadian long-term care facility (Northwood, Halifax, NS), shines a light on the organizational rhythms that quietly, yet powerfully, keep this complex system in motion.

What I found was both surprising and, at times, unsettling. Long-term care is a tough place—not only because of the inevitable organizational systems but because it is fundamentally about aging, decline, and the vulnerabilities that come with them.

The reality of polypharmacy on the ground often looks different from how it is portrayed in textbooks, public discourse or values such a patient centered care. Doctors, nurses, pharmacists, LPN’s--they're not sitting around conspiring to overprescribe. These are smart, dedicated professionals navigating a system that's as much about habit, tradition, and power dynamics as it is about science. And the residents? They're not just passive recipients in this story. Their voices, their choices (or lack thereof), and their lived experiences are an integral part of the narrative.

This isn't a story about individual blame. We need to stop thinking about polypharmacy as something that can be "fixed" if only people tried harder or cared more. It's not that simple. Polypharmacy is a ‘wicked problem’ and the solutions are multi layered and complex. The practice is baked into the very fabric of our institutions. It's a product of routines that feel mundane and are, in reality, deeply powerful.

The effects of polypharmacy aren't just about whether medications are appropriate or excessive. It's also about different dynamics and elements that are part and parcel of any organization. Think hierarchies, bureaucratic tape (forms, endless forms), regulations and policies, understaffing, inefficient or rigid technologies, understaffing, cultural norms that devalue routine work. Whose voices are heard--or ignored--when it comes to decisions about care? How spaces and technologies are organized also matters to how people provide and receive care. The practice of polypharmacy, in its many forms, carries consequences that extend far beyond individual prescriptions, raising questions about autonomy, authority, quality of life, and agency.

This Substack is your invitation to explore those questions with me. We’ll dig into the everyday realities of polypharmacy in long-term care and beyond. We'll explore what it looks like on the ground, what it means for healthcare professionals and residents alike, and why it matters to all of us. This new perspective of understanding polypharmacy brings with it fresh language, new ways of thinking, and important questions that need to be explored. I believe this approach has significant implications for research, medical practice, and education.

Here are some of my interest for this substack:

• What does polypharmacy really look like? My research will take you inside the routines, conversations, and small acts that make up the daily dance of medication management.

• Who's shaping the story? From healthcare workers to patient advocacy groups to government bodies, let’s unpack the roles, motivations, and tensions driving the conversation about polypharmacy.

• What's missing from the research? Let's discuss the blind spots in how the research community studies polypharmacy and the new questions we need to ask if we want to really understand it.

• This isn't just about medications; it's also about the relationships and hierarchies that shape care decisions in ways we often overlook.

Ultimately, this is about changing the way we think and talk about polypharmacy. If we want to move forward--whether through research, medical education, or policy change--we need fresh perspectives, new language, and a willingness to question the status quo.