Essential Takeaways: The Realities of Polypharmacy in Long-Term Care
At Northwood long-term care facility, the invisible scaffolding of polypharmacy—the ceaseless labor that sustains medication work—comes into full view. My ethnographic or real-world empirical research moves beyond the numbers and immerses into the processes: the quiet movement of care unfolding across resident floors and rooms, committees, and the nurses’ rooms. Here, polypharmacy isn’t a static statistic but a living, breathing practice, woven into the fabric of the institution itself.
• 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.