Health & Place 26 (2014) 188–198

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Health & Place

journal homepage: www.elsevier.com/locate/healthplace

The effects of physical environments in medical wards on medication

communication processes affecting patient safety
Wei Liu a,b,n, Elizabeth Manias b,c, Marie Gerdtz a,b
a
Emergency Department, The Royal Melbourne Hospital, Grattan Street, Parkville, Victoria 3050, Australia
b
Department of Nursing, The University of Melbourne, Level 6, Alan Gilbert Building, 161 Barry Street, Parkville, Victoria 3010, Australia
c
Department of Medicine, The Royal Melbourne Hospital, Grattan Street, Parkville, Victoria 3050, Australia

art ic l e i nf o a b s t r a c t

Article history: Physical environments of clinical settings play an important role in health communication processes.
Received 22 October 2013 Effective medication management requires seamless communication among health professionals of
Received in revised form different disciplines. This paper explores how physical environments affect communication processes for
17 December 2013
managing medications and patient safety in acute care hospital settings. Findings highlighted the impact
Accepted 27 December 2013
of environmental interruptions on communication processes about medications. In response to frequent
Available online 15 January 2014
interruptions and limited space within working environments, nurses, doctors and pharmacists
Keywords: developed adaptive practices in the local clinical context. Communication difficulties were associated
Communication with the ward physical layout, the controlled drug key and the medication retrieving device. Health
Medication management
professionals should be provided with opportunities to discuss the effects of ward environments on
Physical environments
medication communication processes and how this impacts medication safety. Hospital administrators
Space
and architects need to consider health professionals0 views and experiences when designing hospital
spaces.
& 2014 Elsevier Ltd. All rights reserved.

1. Introduction potentially detrimental to patient safety (Barach, 2007). Only by

The role of physical environments in patient safety has gained
growing professional and public attention with the release of the
Institute of Medicine (2001) report: Crossing the Quality Chasm.
This report revealed that healthcare is not as patient–centred, safe,
effective, efficient, timely and equitable as it should be. To address
the quality issues enacted by the Institute of Medicine, efforts have
been made to ensure that quality and safety are incorporated into
health professionals0 physical environments (Henriksen et al.,
2007). Physical environments refer to the spaces within which
clinical activities are undertaken. To understand the significance of
spaces in healthcare, we must look into the relations between
people and their situated environments, and how people use the
spaces to facilitate activities and routines (Fox, 1997; Gesler et al.,
2004).
Medication management is a key component of patient safety,
which exists as a continuum of highly complex processes that
requires seamless communication among health professionals of
different disciplines. The multiple steps carried out in healthcare
systems are often at risk of unanticipated outcomes that are
n
Corresponding author at: Emergency Department, The Royal Melbourne
Hospital, Grattan Street, Parkville, Victoria 3050, Australia. Tel.: þ61 432654288.
E-mail addresses: wei.liu10@gmail.com, wei.liu@mh.org.au (W. Liu).
designing safe working environments that facilitate team commu-
nication among health professionals, can medication management
function effectively and safely.
2. Literature review
Physical environments of clinical settings can impact on infor-
mation exchange between doctors and patients (Okken et al.,
2012), nurses and patients (Gray and Kutner, 1983), and among
health professionals of different disciplines (Gum et al., 2012; Li
and Robertson, 2011). Current literature provides evidence on how
people, physical environments and social relationships are inter-
linked to influence communication processes. Okken et al. (2012)
reported that the size of consultation rooms and interpersonal
spaces had a major influence on patient–doctor interactions.
Patients tended to engage in interactions with doctors in large
consultation rooms but with a small interpersonal distance. Gray
and Kutner0 s (1983) study in a renal dialysis clinic revealed that
spatial arrangements of the clinic delineated social boundaries
between patients and nurses, and influenced patients0 care experi-
ences. In the study environment, patients0 chairs were placed in
rows with a large nurse0 s desk positioned at the beginning of the
rows of chairs. Hence, patients rarely had the chance to interact

1353-8292/$ - see front matter & 2014 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.healthplace.2013.12.017
 W. Liu et al. / Health & Place 26 (2014) 188–198
with nurses as nurses often clustered around the large desk
talking and reading.
In line with Gray and Kutner0 s (1983) findings, Li and Robertson
(2011) showed that team communication was facilitated in physi-
cal spaces where health professionals sat in semi-circles rather
than in rows. Semi-circular seating arrangements encouraged
participants who sat in the peripheral areas to contribute informa-
tion for discussions. Also of importance is the effect of the design
of nurses0 stations on interprofessional collaboration. Gum et al.0 s
(2012) study revealed that a lack of space and privacy in nurses0
stations created communication barriers among healthcare team
members. The nurse0 s station was used by healthcare team
members to document clinical notes and engage in social and
professional interactions. The investigators argued that the nurse0 s
station was not only a physical space, but was a social space.
Although aforementioned studies provide insights into com-
munication processes within physical environments, these studies
have mainly focused on general communication encounters rather
than medication interactions. Investigators have not addressed the
interconnectedness between physical environments, communica-
tion processes and medication management. Without clarifying
the spatial contexts within which health professionals carry out
their daily medication interactions and activities, the issue of
medication safety cannot be adequately addressed.
In hospital settings, communication within space is also deter-
mined by health professionals0 movements and accessibility to
other people. Nurses tend to congregate in the medication room
and communicate between each other during medication prepara-
tion. Manias et al. (2005) found that nurses did not necessarily
follow through each other to the patient0 s bedside for medication
communication and double-checking due to physical distance
between the medication room and the bedside and to time
constraints. Nurses0 low compliance with double-checking proce-
dures due to physical boundaries and geographic separations has
been reported by Sanghera et al. (2007). In Sanghera et al.0 s work,
nurses working in isolation rooms found it difficult to access and
communicate with colleagues about medication management.
Therefore, those nurses had no choices but to administer medica-
tions without a second check.
While these two studies Manias et al. (2005), Sanghera et al.
(2007) have a specific focus on the contextual influences of
physical environments on nurses0 medication activities, the effects
of working environments on communication processes between
health professionals of different disciplines during medication
management have remained unexplored. Without clarifying the
social influences of medication activities, health professionals will
not consider how their habitual practices within specific clinical
environments contribute to existing social relationships. Previous
studies (Li and Robertson, 2011; Manias et al., 2005; Okken et al.,
2012) have tended to examine space as physical settings involving
environmental design and spatial arrangements, with little con-
sideration given to the theoretical background of space. Yet, as
demonstrated by Gum et al. (2012), the physical location of nurses0
stations imply symbolic power and social status. It is important to
draw on theory to explore the ways in which space is organised
and utilised in specific clinical contexts.
This paper draws upon four theoretical aspects of space and
place – the spatial becomes the social (Pred, 1985), space–time
geography (Giddens, 1985), social relations in space (Gesler, 1999)
and discourses and places (Gesler, 1999). The theorisation of space
and place can be traced back to Pred (1985). According to Pred
(1985), space is a reflection of social structure. It is a social product
and an integral part of the structuration of social life. Place
represents a human product. It is characterised by a flux of human
practice in space. In the process of “becoming” a place, individuals
act within the constraints and opportunities of spatial structures
189
(Pred, 1985, p. 338, emphasis in the original). For example, when it
comes to allocating time resources for different activities, time
may be reprioritised by health professionals to permit the com-
pletion of necessary activities by pushing aside other competing
activities. In this sense, becoming a place depends on synchronis-
ing social activities within given temporal–spatial structures. It
involves an ongoing process of social division of material and
labour (Pred, 1985).
The concept of space–time geography (Giddens, 1985) is built
upon Hagerstrand0 s (1982) work, which emphasises the identifica-
tion of sources of constraint over human activity in day-to-day life.
According to Hagerstrand (1982), human beings have limited
capacity to participate in more than one task at once. Two
individuals cannot occupy the same space at the same time.
Despite Hagerstrand0 s attempts to integrate temporality into social
theory, he has not rigorously scrutinised the notion of place
(Giddens, 1985). For Giddens (1985), place is not simply “a point
in space” (p. 271). It refers to the use of space to provide the
settings of social interactions. For example, houses are settings
that provide physical dwellings for human activities. Furthermore,
these settings play a strategic role in regulating routinised social
practices. In healthcare, Zerubavel (1979) mapped out formal
patterns of time in a modern hospital through enactment of
clinical practices. Zerubavel found that nurses always standardised
medication administration times in accordance with their own
schedules to avoid conflicts with their handover times or meal-
times. In this sense, nurses0 administration of medications was
structured on a social basis and affected by socio-temporal
constraints.
Any social process inevitably involves complex social relations.
Pred (1985) believes that power, as a social relation, has the
capacity to control the time-space path. Leibniz (2000) advocates
a relational theory of space. According to Leibniz, there is no space
without things or activities placed in it. Space has no power in
itself. Instead, the formation of space depends on the things and
activities that occur within specific locations or places. A place
refers to a location, occupation or frequentation of a space. Gesler0 s
(1999) influential work on Words in wards contextualised the
intrinsic link between power and place in healthcare. For Gesler,
power is manifested in medical situations; it is felt in situated
activities and concrete medical settings. For example, during ward
round discussions, senior attendings often explicitly express their
experiential knowledge to junior residents and determine treat-
ment decisions. Attendings0 experiential knowledge is powerful as
it is locally contextualised and grounded in the practices of
particular places (Atkinson, 1995). The doctor–patient relationship
can also be influenced by places such as a private practice office or
a clinic examination cubicle (Fisher and Todd, 1993). Fisher (1993)
examined doctor–patient communication about treatment
decision-making in two clinics of a university teaching hospital.
The Faculty Clinic was staffed by senior professors, and most
patients were referred by other medical practitioners in the
community. The Community Clinic was staffed by junior residents,
and most patients were referred by social agencies or other clinics
in the hospital system. In the Faculty Clinic, there was a separation
of public and private space. There was no such spatial separation
in the Community Clinic. Fisher reported that, although the
doctor–patient relationship was known to be an asymmetrical
one, the asymmetry increased when patients were consulted by
residents in the Community Clinic. In comparison, patients were
given more treatment options by professors in the Faculty Clinic.
Todd (1993) explored communication patterns between female
patients and their doctors about contraception and health needs.
Todd0 s study further demonstrated how male doctors often
controlled the flow of communication with female patients and
the various ways in which female patients resisted medical
190 W. Liu et al. / Health & Place 26 (2014) 188–198

domination. Similarly, Fox (1993) examined the power struggles
between surgeons and patients during surgical ward rounds. Fox
noted the “minute-to-minute” strategies used by surgeons to
disempower patients who tried to set the agenda of medical
encounters (p. 22). In his critical theorisation of medical encoun-
ters, Waitzkin (1989) claimed that medical domination in health
reinforces broad social structures and existing social orders.
Gesler0 s (1999) work is important also because of its emphasis
on the inextricable link between language and place. Gesler
advocates that, to discover people0 s interpretation of places, we
need to understand local language that is contextualised to
situational practice. In healthcare, language has been increasingly
analysed as discourse, a naturally occurring and locally organised
social product (Fisher, 1993). Health professionals often shift their
language discourses in different places. When talking with collea-
gues in the operating theatre, they use technical terms such as
“myocardial infarction;” whereas, when talking with patients in a
consultation room, they attune their language to “heart attack”
(Gesler, 1999, p. 17). Many medical discourses that affect social
relations have emerged from the literature, including task com-
pletion, technology, normalisation, collaboration, efficiency,
patient care, staff socialisation, safety and policy (Table 1). These
discourses are also explored in our findings.
In this paper, we draw upon theoretical aspects of space and
place to explore the influences of physical environments on
medication communication processes. For the purpose of this
paper, we define medication communication as interactions
among doctors, nurses, pharmacists and patients about medica-
tion management activities.
3. Methods
3.1. Methodological approach
Critical ethnography involves participants engaging in the
process of reflexivity to make meanings of their practices in their
own social world (Manias and Street, 2001). In this study,
participants reflected on the research data and challenged their
daily practices and working environments. Through reflexivity,
participants were able to understand the meanings of physical
space in constructing clinical practices and social relationships,
and to make recommendations for practice changes.
3.2. Research sites and participants
This study was undertaken in two general medical wards
(Ward 1 and Ward 2) of an acute care hospital in Australia. All
registered nurses, doctors and pharmacists were eligible for
participation during the study period from January to November
2010. Patients were eligible if they were competent to commu-
nicate with health professionals during medication management.
Patients were required to speak English, to be medically stable and
not be confused. In-service meetings were organised among staff
members to introduce the study and to invite for participation. The
first author of the paper approached patients individually after
obtaining consent from staff members. Staff members also assisted
the first author to determine the appropriateness of patients0
participation in the study. Across the two medical wards, 76
nurses, 31 doctors, one pharmacist and 27 patients gave written
consent to participate in the study. Six patients declined participa-
tion after being approached. Verbal consent was sought from
family members and health professionals who showed up unex-
pectedly during the observation, including four family members,
two pharmacists, eight doctors, two social workers and four
physiotherapists. Nurse participants included the nurse unit man-
agers (NUMs), nurse coordinators, clinical nurse specialists (CNSs)
and staff nurses. Medical participants comprised medical resi-
dents, medical registrars and medical consultants.

The methodological approach selected for this study was

critical ethnography. Critical ethnography considers the taken-
for-granted political and social assumptions of individuals0 activ-
ities (Schwandt, 2007). It involves an examination of culture for
the purpose of thinking about aspects in different ways. From a
critical perspective, physical space is viewed as a social context
that develops through social practices, power relations and ideo-
logical structures (Fairclough, 2006). Our intention in the study is
to understand the contextualised medication communication
practices and broad social relationships surrounding these com-
munication practices, by making physical space visible in the
research process and contesting individuals0 use of physical space.
3.3. Data collection
The hospital and university ethics committees gave approval to
carry out the project. Data collection methods included participant
observations, field interviews, video-recordings and video reflex-
ive focus groups (Table 2). Table 2 shows how rigour was
addressed in the different data collection methods used in the
study. This study draws on data from 290 h of participant
observations, 72 field interviews, 34 h of video-recordings and
five reflexive focus groups. The first author collected the
research data.

Table 1
Medical discourses affecting social relations.

Discourse Description of discourse in specific contexts Reference

Task completion Nurses completed medication administration tasks within rigid time frames. Zerubavel (1979)
Technology Doctors relied on technologies to “read” the patient0 s body. Atkinson (1995)
Normalisation Doctors recommended a treatment option to the patient because it was the “usual” or Fisher (1993)
“normal” way to treat her condition.
Collaboration Decision-making processes were dispersed across different personnel and different Atkinson (1995)
hospital sites.
Efficiency The hospital day surgery unit represented an efficient “well-oiled machine” where staff Fox (1999)
achieved a smooth production line of patients successfully treated.
Patient care Professors at the Faculty Clinic used questioning strategies to assess individual patients0 Fisher (1993)
competence.
Staff socialisation Doctors at different professional levels met in groups after hospital work. Zerubavel (1979)
Safety Health was defined as individuals0 ability to get back to work safely. Waitzkin (1989)
Policy Doctors proceeded in their professional career along with a rigid hospital rotation Zerubavel (1979)
system.
 W. Liu et al. / Health & Place 26 (2014) 188–198 191

Table 2
Data collection methods.

Data collection Data collection procedures Rigour establishment

methods

Participant Participant observations focused on health professionals0 communication activities The first author made frequent visits to the study
observations during medication management and looked for evidence of the environmental influence sites and conducted persistent participant
on those activities. observations over a three-month period of time in
Participant observations were recorded on field notes. The ward physical layout was each ward.
drawn on field notes.
Participant observations aimed to gain a general understanding of how medication
communication activities were undertaken within the ward environments.
Field interviews Semi-structured field interviews were conducted with individual nurses, doctors and Health professionals0 perspectives of observed
pharmacist after the observation. Field interviews focused on participants0 perspectives activities were elicited to triangulate the data.
of the observed activities and their working environments. Field interviews were audio-
recorded.
Video-recordings Group (e.g. nursing handovers, medical ward rounds) and individual (e.g. nurses0 Video-recordings presented rich contexts within
medication rounds, pharmacists0 organisation of discharge medications) medication which communication events were played out.
communication activities occurring at different locations (e.g. staff station, medication
room) were video-recorded using a hand-held video camera.
Video-recordings aimed to gain a genuine record of the environmental contexts within
which medication communication took place.
Reflexive focus groups A reflexive DVD was produced from raw video-recordings and used to stimulate Participants were provided with opportunities to
discussions during focus groups with staff members. review the research data and preliminary findings.
Focus groups aimed to encourage participants to reflect on their daily practice and to
challenge the impact of working environments on communication processes.

Table 3
Data analysis guide (developed from Fairclough (1992)).

Level of analysis Content of analysis Detailed analysis questions

Level one The pronouns, metaphors and
humour expressed in the text.
Level two The situated meanings and values
attached to people, time and space
pertinent to the conversation.
Level three The clinical and social influences of
the discursive practice.
What was the spatial layout of the ward? What participants were saying during
medication management activities? What aspects of patient0 s care were prioritised in
clinical practice?
What discourses were drawn upon by participants to construct their conversations?
How participants used spaces during medication communication activities? What
power relations were embedded in participants0 use of space? How participants
developed strategies in response to environmental constraints?
What was the effect of physical environments on communication practices and
patient outcomes? Did the medication communication practice strengthen or
challenge traditional social relationships?

3.4. Data analysis
The first author carried out data transcribing. On the comple-
tion of transcription, all audio, video and written data were
imported into NVivo 8 (QSR International). All authors undertook
independent analysis of the research data. Data analysis was
guided by Fairclough0 s (1992) three-level discourse analytic frame-
work (Table 3).
3.5. Physical layout of the medical wards
for doctors and pharmacists. Nurses did not have designated
working spaces in the ward.
In Ward 1, the front staff station and the back staff station were
used by all staff members to discuss, plan and record patient care.
The medication room remained locked at all times. To retrieve
medications, nurses needed to access the medication room using a
swipe card. Only permanent nursing staff and the ward pharma-
cist were permitted to carry swipe cards. The ward pharmacist
often sat at the pharmacist0 s desk to review medication charts. The
doctors0 desk was used by the medical team during ward rounds to
discuss patient progress and plan patient care (Fig. 1).

Both medical wards had single-bed and multi-bed rooms,

which were positioned alongside the ward corridors. The multi-
bed rooms accommodated 2–4 patients. There was a central
medication room in each ward. Staff stations on the ward func-
tioned as major sites for interdisciplinary interactions.
3.5.1. Physical layout of ward 1
Ward 1 had 30 patient beds dispersed alongside the front and
back corridors. A front staff station and a back staff station were
located in each corridor. The medication room was located at the
junction where two corridors joined together. The medication
room retained shelves and cupboards that were built in to store
imprest medications on the ward. Next to the reception desk at the
ward entrance, separate desks were designated as working spaces
3.5.2. Physical layout of ward 2
Renovations had just been completed in Ward 2 before the
study was undertaken. Ward 2 had 32 beds after the renovations.
At the time of data collection, there were only 19 operational beds,
which were dispersed alongside five corridors. The ward was in
the process of staff recruitment before opening more beds at that
time. Another reason why some patient rooms were not in use was
the limited space available in those rooms. As a result, those rooms
were used to store equipment such as intravenous poles and
infusion pumps.
After the renovations, a medication retrieving device (Pyxis)
was installed in the medication room. The Pyxis stored imprest
medications used in the ward. To retrieve medications for a
patient, nurses needed to access the Pyxis with an individualised
192 W. Liu et al. / Health & Place 26 (2014) 188–198
Fig. 1. Spatial arrangements of Ward 1.
username and biological fingerprint marker. A medication record
was automatically generated for the patient after medications
were removed from the Pyxis. Installation of the Pyxis aimed to
streamline workflow, track medication records and improve
patient safety.
A central staff station was located next to the medication room.
There were no individually-designated working spaces for nurses,
doctors and pharmacists. They were all based on the central staff
station, working together with allied health professionals. The central
staff station was used as a focal point for interdisciplinary interactions.
A staff substation was located at the entrance of the ward and out of
visual contact from the central staff station. The staff substation was
mainly used by nurses who were assigned to care for patients in the
area. Both the central staff station and the staff substation were also
used by the medical team during ward rounds to discuss patient care.
Although the medication room was open to all staff on the ward, it
was mainly accessed by nurses and pharmacists (Fig. 2).
4. Results
The physical environments of the two medical wards had a
major influence on medication communication processes. Nurses,
doctors, pharmacists and patients communicated about medica-
tion management in interruptive environments. In response to
frequent interruptions and spatial limitations, health professionals
developed adaptive practices in the local clinical settings. Com-
munication difficulties were associated with the ward physical
layout, the controlled drug key and the medication retrieving
device.
4.1. Environmental interruptions
Both medical wards were workplaces with a high intensity of
clinical activities. Due to a lack of space, there was often physical
crowdedness on the wards. Patient trolleys, wheel chairs, equip-
ment trolleys jostled against each other in the corridors. The ward
space was cramped with constant noise from overhead paging
announcements, equipment cycling, trolley rolling, phones ringing
and people conversing.
Spatial arrangements contributed to environmental interrup-
tions during medication activities, as explained by the pharmacist
in Ward 1:
The interruptions come when I sit at the [pharmacist0 s] desk, that0 s
where the pharmacy tray is, where people leave all medication
orders and discharge scripts. It0 s okay in the morning and early
afternoon when the receptionist is at the front. But in the late
afternoon, she finishes early, so I have all the inquiries from visitors
when they come in. I try to help, or I have to send someone else to
help. (Pharmacist, Interview #7, Ward 1)
In Ward 1, the pharmacist0 s desk was located next to the
reception at the ward entrance. The pharmacist expressed her
frustration in facing frequent interruptions from visitors0 inquiries.
Only one pharmacist was employed in the ward. The pharmacist
spent a significant amount of time at the pharmacist0 s desk on the
shift, reviewing medication orders and organising medication
delivery from the central pharmacy department to the ward.
However, the location where the pharmacist occupied most of
the time throughout her shift was subjected to repeated interrup-
tions from visitors. In Ward 1, the doctors0 desk was located behind
the reception desk and the pharmacist0 s desk, rendering less
visibility to visitors. In order to visit patients on the ward, visitors
had to first pass the reception desk then the pharmacist0 s desk.
Most visitors0 inquiries were addressed by the receptionist or the
pharmacist when they entered the ward.
The medication room in Ward 1 highlighted a lack of space for
nurses to conduct medication preparation activities. The medica-
tion room stored imprest medications on shelves and controlled
drugs (e.g. opioid analgesics) in a locked cupboard. The medication
room had a high traffic of mobility throughout the day due to the
large number of medications prescribed to patients in the ward.
Nurses frequently walked in and out of the medication room to
retrieve medications. However, the medication room was very
small. Due to the limited space in the medication room, nurses
 W. Liu et al. / Health & Place 26 (2014) 188–198 193

Fig. 2. Spatial arrangements of Ward 2.

chose to prepare medications in the front and back staff stations

that were originally designed for interdisciplinary interactions,
leaving space in the medication room for double-checking of
controlled drugs. However, the front and back staff stations were
highly susceptible to interruptions from different sources – col-
leagues passing by, people0 s conversations and most prominently,
constant telephone ringing. The following text was involved a
video observation of a nurse preparing intravenous antibiotics in
the front staff station:

The phone started to ring when the nurse was drawing up the
Normal Saline solution. She had a quick look around the staff
station. There were two doctors sitting around the desk and
reading patients0 notes. The nurse put the syringe down on the
bench and picked up the phone. The call was from the
pathology department, providing test results of a patient who
was under the care of another nurse in the back corridor. The
nurse wrote down the results on her handover sheet, and she
then called the back staff station, trying to speak to the nurse
Fig. 3. Nurse answering a phone while preparing medications in the front staff
who was looking after the patient. There was no one picking up
station.
the phone at the back staff station. The nurse hung up the
phone and walked to the back corridor looking for the other
nurse. Soon after she came back to the front staff station and medication preparation activities. On the other hand, she needed to
continued with her medication preparation, the phone started answer the phone calls. The administrative task of answering phone
to ring again. The nurse picked up the phone. The call was from calls was ingrained in nursing practice. Although both the nurse and
a family inquiring about a different patient who was located in the doctors heard the phone ringing in the staff station, it was the
the back corridor. The nurse transferred the call to the back nurse who settled into her normalised practice and answered the
staff station and hung up the phone. The nurse joked that it is phone calls. There was an imbalance between the discourse of
part of her job doings “phone management.” (Fig. 3) (Staff normalisation and the conduct of medication preparation activities.
nurse, Video observation #18, Ward 1). The nurse0 s use of humour when speaking about her “phone manage-
ment” skills acted as an indirect form of resistance to her involvement
In this scenario, the nurse was interrupted twice by phone calls in answering telephones while preparing medications.
during medication preparation activities in the staff station. The nurse This scenario shows there were tensions created by the spatial
was multitasking. On the one hand, she needed to concentrate on her context. Not only were the nurse0 s medication preparation
194 W. Liu et al. / Health & Place 26 (2014) 188–198

activities undertaken in an open staff station and subjected to

various environmental interruptions, the nurse also had to move
between different spaces from the front staff station to the back
corridor during the medication preparation process. In contrast,
the doctors were able to focus on their activities of reading
patients0 notes in the staff station. Based on observational data,
it was common that medical activities were conducted in a more
coordinated and coherent way than nursing activities.
While doctors typically spent their time in staff stations
conversing about patients0 management, interruptions to medical
conversations were also prevalent, especially among senior doc-
tors. In both wards, medical consultants and medical registrars
carried mobile phones, which constantly rang during ward rounds.
They answered phone calls promptly and regularly exited formal
meetings to deal with urgent clinical issues. Doctors were respon-
sible for patients assigned to specific teams according to patients0
medical conditions. However, patients assigned to specific medical
Fig. 4. A pharmacist conducting medication education before patient discharge in
teams were not always allocated to one particular ward. Therefore,
Ward 1.
doctors relied on mobile phones or pagers to remain in contact
with other colleagues and to manage their patients beyond the
confined ward space.
Although interruptions and multitasking were accepted by
health professionals as an indispensable part of clinical work,
interruptions and multitasking influenced patient safety. For
example, interruptions to conversations encouraged health profes-
sionals to leave their conversations unfinished in order to com-
plete other activities. Health professionals had to make additional
effort to clarify information when returning to suspended discus-
sions and as a result, medication administrations were sometimes
delayed.

4.2. Adapting to the space

Nurses, doctors and pharmacists were observed to undertake

adaptive practices during medication management in response to
environmental constraints. In Ward 1, nurses altered their practice
by preparing medications in the front and back staff stations due
to spatial limitations in the medication room. As there was no
designated working space for health professionals at the patient
bedside in Ward 1, they used a bedside table or patient bed to
conduct clinical activities such as medication education (Fig. 4).
Fig. 4 demonstrates the conduct of medication education by a
pharmacist before patient discharge. The pharmacist seemed to be
rushed. She walked into the patient0 s room and emptied the
discharge medications from a paper bag directly onto the patient0 s
bed. During the medication education, both the pharmacist and
the patient stood next to the bedside. The standing position taken
up by the pharmacist and patient implied a sense of completing
the education and getting the patient home. The interactions were
focused on explaining and clarifying new medications prescribed
for the patient. The pharmacist did not assess the patient0 s
medication knowledge, nor did she actively encourage the patient
to raise his education needs about the discharge medications.
Moreover, two layers of spatial vulnerability were embedded
in Fig. 4. First, there was a lack of designated working space at the
patient bedside. Health professionals had to construct their own
working space at the immediate scene. Second, patients0 personal
space was encroached by health professionals when required.
Health professionals used patient beds to conduct bedside med-
ication activities.
After the renovations in Ward 2, benches and computers were
installed at the bedside to provide space for bedside documenta-
tion and to allow easy access to clinical information. However,
nurses, doctors and pharmacists tended to congregate in the
central staff station, competing for space to write clinical notes
and use computers, even at the cost of kneeling on the ground
Fig. 5. Staff members congregating in the central staff station in Ward 2.
(Fig. 5). Nurses attributed their dislike of using bedside benches for
documentation to many reasons. Some nurses explained their
movement away from the bedside as a mechanism to minimise
“questioning from patients” or “distraction by patients while
writing notes.” Another nurse explained it in terms of normalised
practice, saying that, “I don0 t have the habit of writing notes at the
bedside.” It appeared that the location of nursing work was
organised around nurses0 routines and rituals, rather than indivi-
dual patients0 needs. Another nurse explained that “I go to the staff
station because I need a seat even just for two seconds to rest my
legs.” This comment revealed the busyness and pressure of bed-
side nurses. Nurses also adhered to a social discourse, saying that,
“We are social professionals,” or “We sit in the staff station to have
a bit ‘us’ time.” Nurses0 use of pronouns “we” and “us” implied
collegial solidarity in the nursing profession.
Similarly, doctors and pharmacists preferred to use the central
staff station for documentation because of its easy access to other
colleagues and fewer interruptions from patients and families at
the bedside. During the observation periods, nurses, doctors and
pharmacists spent little time documenting at the patient bedside
or involving patients in lengthy discussions about medications.
The discourse of patient–centred interactions seemed to give away
to the discourse of team collaboration in health professionals0 use
of space for documentation.
 W. Liu et al. / Health & Place 26 (2014) 188–198 195

Bedside computers in Ward 2 were also not efficiently used by
health professionals to communicate clinical information. Nurses,
doctors and pharmacists raised concerns about privacy because
they could not log on and off bedside computers in a timely
manner. It appeared that the hospital introduced the information
technology at the bedside without considering the clinical con-
texts of communication processes. The discourse of technology did
not take account of patient privacy issues. Computer malfunction-
ing was another issue. While hospital administrators made struc-
tural changes to improve efficiency, the technical support for
communication processes provided in local ward environments
were inadequate, affecting daily clinical practice.
4.3. Communication difficulties associated with physical
environments
4.3.1. The ward physical layout
Ward 2 was located on the ground floor of the hospital without
windows and without clear direction signposts across five corri-
dors. Staff reported that it was difficult to move around because
the corridors looked similar with few differentiating features. The
NUM of Ward 2 elaborated on the effects of the ward design on
staff and patients:
needed to be kept in locked bedside drawers. Nurses carried the
keys for these drawers. After renovations in Ward 2, the medica-
tion drawers were relocated to the furthest corners of each room.
Nurses had to over-reach to unlock and relock the drawer each
time medications were removed (Fig. 6). The issue of occupational
health and safety was often brought up by nurses during observa-
tions and interviews. Although nurses needed to frequently access
bedside drawers during medication rounds, the location of those
drawers decontextualised nurses0 needs for medication retrieval,
which might potentially prolong the medication administration
process. Nurses were positioned in tensions created by the
hospital policy, the ward design and the contextual realities.
In addition, the ward design affected staff0 s mobility and
communication processes. In the newly renovated Ward 2,
patients0 notes were required to be placed in the locked cupboard
at the bedside. However, in reality, patients0 notes were often
taken away by health professionals of different disciplines and left
in the staff stations or misplaced elsewhere. Staff spent a con-
siderable amount of time walking around in circles and looking
for patients0 notes. These searching activities often disrupted
the linear structure of communication processes and affected the
continuity of work flow.

The ward can be claustrophobic. When they [hospital architects

and administrators] designed the ward, it was based on the 4.3.2. The controlled drug key
assumption of the ward0 s high turn-over. Patients should either In Ward 1, controlled drugs such as opioid analgesics were
go home or go to another ward after 48 h. But sometimes we stored in a locked cupboard in the medication room. There was no
have medical patients on the ward for 10 days. Patients get designated person to carry the key to this cupboard. As time
more agitated and delirious after being blocked from sunlight passed, the key was randomly relayed liked a baton among nurses
for a few days. They need vitamin D tablets. It also affects staff0 s who were allocated to work in different corridors. Whenever a
mood. (NUM, Interview #43, Ward 2) nurse needed to access a controlled drug, she or he had to call out
loudly for the key while walking around the corridors and looking
According to the NUM, the spatial design of the renovated for the nurse who used the key last time. Sometimes, nurses who
Ward 2 could not meet its clinical demands. While hospital carried the key were busy with patients. They did not hear other
architects and administrators designed the ward with the dis- nurses0 calls. Sometimes, nurses simply forgot that they had the
course of efficiency aiming for rapid patient flow, it was difficult key with them. Then, buzzers rang and the nurse searching for the
for staff members to communicate about ever-changing demands key was called away for another job and returned to the search
in real clinical situations. The NUM0 s comments were echoed by again. All of these events had negative consequences on patients0
other staff who admitted that working on the ward throughout the medication management and clinical efficiency. The following
week adversely affected their mood. focus group excerpt was taken after nurses watched video exam-
Patients described their feelings of spatial enclosure created by ples of themselves looking for the controlled drug key:
four white walls. A patient metaphorised her ward experience as
“in prison because everything is closed.” Another patient felt Staff nurse 1: Oh, poor [name the nurse in the video]. That0 s
“deskilled” because she could not self-administer her insulin in what we do every day.
the ward due to inadequate lighting. Since Ward 2 was located on
the ground floor of the hospital, the ward had to rely on artificial
lighting. A few patients reported that the artificial lighting in the
ward affected their vision. Sometimes, patients interacted with
each other about the time differentials between their personal
schedules of taking medications at home and standardised med-
ication rounds at the hospital. Patients felt that they had to change
their own schedules to conform to the hospital schedules. In
addition, there was a lack of patient privacy and space in multi-
bed rooms. Family members were often observed carefully walk-
ing into a multi-bed room and entering into specific locations of
the room where the patient was placed. Nurses, doctors and
pharmacists always drew curtains to create some temporary
spatial boundaries when interacting with patients and family
members in a shared room. However, noises still transcended
curtains. In this context, curtains only represented an appearance
of privacy that existed in a limited extent in a visual rather than an
aural sense. The ward environments had impacted on patients0
care experiences.
The ward design also affected nurses0 medication management
activities. According to the hospital policy, patients0 medications Fig. 6. A nurse over-reaching to access a patient0 s medication drawer.
196 W. Liu et al. / Health & Place 26 (2014) 188–198
Staff nurse 2: Exactly. We walk miles every day looking for the
key. We should ask one person to carry the key, maybe the
nurse coordinator.
Nurse coordinator: I guess we can as long as everybody
remembers not to take the key when leaving [the ward] for
[organisational] meetings.
Staff nurse 3: I think you have to find a better time to give
controlled drugs. You don0 t give them at the beginning of the
shift because everybody is busy doing morning medications.
It0 s hard to find the key and the person to check with you.
Staff nurse 2: Maybe we can colour the key [lanyard], making it
green to stand out. Where I used to work, we used a chain, a
heavy chain, so you know you have it. (Focus group #1, Ward 1)
By critically viewing and reflecting on their daily practice, nurse
participants in the focus group showed empathy and understand-
ing to each other in having to cover enormous distances in
searching for the controlled drug key. They made suggestions for
practice change such as allocating nurse coordinators to carry the
key and making the key easily identifiable. The reflexivity enabled
nurses to challenge the taken-for-granted medication communi-
cation activities. Nevertheless, nurse participants did not examine
the controlled drug key issue from an organisational perspective.
They did not consider the burdening effect of carrying a key
throughout the shift and numerous interruptions during their
search for the key.
According to the hospital policy, controlled drugs needed to be
double-checked by two nurses when they were taken out from the
locked cupboard and when they were administered to the patient
at the bedside. During observations, all nurses double-checked
controlled drugs when they were taken from the locked cupboard
in the medication room. However, there were two occasions
where double-checking controlled drugs to the patient0 s bedside
for administration did not happen. In both situations, the second
nurse did not follow through the other nurse to the bedside in the
front corridor because she was assigned to work in the back
corridor. When interviewed after observations, nurses acknowl-
edged the importance of double-checking medications to the
patient0 s bedside for administration. However, they commented
that the spatial separation on the ward made it difficult for them
to follow through each other to the bedside to complete the
double-checking process. There were tensions between the orga-
nisational discourse of written policies and nurses0 compliance
with standard policies in specific clinical environments.
4.3.3. The Pyxis device
At the time of data collection, there was one medication
retrieving device (Pyxis) used for 19 patients in Ward 2. Nurses
had to queue up to retrieve medications from the Pyxis (Fig. 7). It
was particularly time-wasting during morning shifts when most
patients had many medications prescribed at eight o0 clock. Nurses0
congregation in the medication room early in the morning had a
potential impact on patient safety as patients were left unattended
at the bedside.
Some nurses commented about the effects of the Pyxis in their
communication with patients and student nurses, saying that, “It0 s
hard to explain to patients what the tablets are because you don0 t
have the original pack with you,” or “I don’t have time to go
through with students about the medications because I want to
get it done as timely as possible.” Although nurses perceived
medication education as part of their role, it could be a time-
consuming process, particularly with the use of new technology
for managing medications. There were barriers created by tech-
nological innovations, normalised practice and clinical efficiency.
Other nurses reported that they felt nervous and distracted when
Fig. 7. Nurses queuing up to retrieve medications from the Pyxis during morning
medication rounds in Ward 2.
their colleagues engaged in social chatting while waiting for access
to the Pyxis. A nurse commented at her interview, “I cannot
concentrate because I feel people breathing down my neck.” In
this situation, the discourse of socialisation was in tension with the
medication retrieval activities that required focused concentration.
With the introduction of the Pyxis device, the issue of nurses
searching for the controlled drug key was resolved in Ward 2. To
retrieve a controlled drug from the Pyxis, two nurses0 biological
fingerprints were required. Since the Pyxis was located in the
medication room and nurses spent a significant amount of time in
that area, double-checking controlled drugs from the Pyxis was
relatively easy. However, the use of the Pyxis had increased nurses0
low adherence to double-checking controlled drugs at the bedside.
The follow-through to the bedside meant that nurses had to leave
the medication room, to lose their position on the waiting line for
access to the Pyxis after coming back, and to rejoin the queue
again. Nurses0 low adherence to the double-checking policy had
significant implications for patient safety. This practice increased
the possibility of medication overdosing or administration of
wrong medications to patients.
5. Discussion
Our study highlighted the impact of physical environments on
communication processes for medication management. The dis-
course of task completion taken up by health professionals was
prioritised in clinical practice. Health professional–patient inter-
actions about medication management were largely centred on
accomplishing specific medication tasks within particular tem-
poral and spatial limits. The ward physical environments also
revealed competing discourses between organisational enactment
of technologies and health professionals0 implementation of tech-
nologies in daily clinical work.
Aspects of the spatial context that impacted on interruptive
patterns of communication between different disciplines have
emerged from the study. The disciplinary hierarchy between
medicine, pharmacy and nursing was demonstrated by health
professionals0 working spaces, which supports Spain0 s (1992)
notion that “higher status within an organisation is accompanied
by greater control of space” (p. 218). Although doctors were
exposed to a variety of environmental interruptions like pharma-
cists and nurses, doctors were provided with enclosed working
spaces where they could withdraw when needed. The physical
 W. Liu et al. / Health & Place 26 (2014) 188–198
location of the pharmacists0 working spaces rendered pharmacists0
work highly visible to visitors. Nurses, on the other hand, had no
designated working spaces in the ward. They shared open staff
stations with other health professionals when conducting medica-
tion preparation activities. The spatial arrangements of working
spaces reflected distinctions of occupational status and disciplin-
ary power relations. In other words, the existing social structures
around health professionals helped to generate the specific places
in which doctors, pharmacists and nurses located themselves. The
activities and conversations occurring in these places reinforced
the existing social structures and power differentials between the
health professions (Waitzkin, 1989).
Of significance was the development of health professionals0
adaptive practice in response to ward spatial constraints. Due to
the lack of working space at the patients0 bedside, nurses, doctors
and pharmacists in Ward 1 transformed patients0 beds into work-
ing spaces for medication activities such as education. Health
professionals0 use of patient bedside area for the conduct of
medication communication activities demonstrated workload
pressures of health professionals. In order to complete certain
medication tasks within fixed schedules of shift work, health
professionals had to optimise spatial resources to achieve clinical
goals (Fairclough, 2006; Giddens, 1985). The discourses of task
completion and clinical efficiency were embedded in health
professionals0 use of space for medication communication.
Patients demonstrated little resistance to health professionals0
free use of their bed for the conduct of medication activities and
communication. Patients remained silent about their loss of
control over personal space, perpetuating traditional health pro-
fessional–patient relationships of power (Fairclough, 1992).
Interestingly, health professionals did not utilise new bedside
benches in Ward 2 for documenting medication orders and
communicating about medication activities. Health professionals
defended their position with the social discourse of normalisation
and the professional discourse of team collaboration. The normal-
isation discourse depended upon health professionals0 habitual
activities that informed medication communication in ward
spaces. Health professionals demonstrated the habit of document-
ing patient care at a space away from the bedside. The collabora-
tion discourse highlighted health professionals0 preference to
engage in face-to-face medication interactions in staff stations.
The location of medication communication activities was largely
based on health professionals0 needs rather than the provision of
patient–centred care. Health professionals used patient beds as
working spaces when they needed to converse with patients. They
moved away from the bedside area when patients0 presence was
not required. The social and professional discourses taken up by
health professionals were prioritised over the patient–centred
discourse during medication communication processes.
Our findings highlighted many spatial challenges to health
professionals0 medication communication activities. Nurses, doc-
tors and pharmacists spent a lot of time throughout the shift
finding patients0 notes during communication and management of
medications. It was during health professionals0 repetitive travel-
ling across different ward spaces that multiple interruptions
occurred, time was wasted, and medication administration was
delayed. The impact of spatial separation on communication
processes was also identified in the literature (Gum et al., 2012).
In particular, nurses0 administration of medications reflected the
temporal organisation of clinical activities in specific clinical
contexts. While physically moving themselves across the ward
space from the medication room to individual patients0 rooms,
nurses organised medication rounds as a “collective” activity
involving individual patients receiving medications at “standard
medication times.” Nurses0 primary concern was to finish their
medication rounds within specific time frames rather than to
197
administer medications according to individual patients0 schedules
(Zerubavel, 1979, p.107).
Similar to the findings of Manias et al. (2005) and Sanghera
et al. (2007), nurses demonstrated that spatial separation con-
tributed to their low compliance with the medication double-
checking policy. It is assumed that resistance always coexists with
power (Todd, 1993). Nurses showed resistance to spatial con-
straints in working environments by taking a shortcut in the
organisational policy. In their attempts to complete particular
tasks in constrained temporal–spatial environments, nurses were
unable to achieve the expected organisational standards. Although
nurses0 struggles to balance clinical work and standard practices
had no direct effects on the formulation of organisational policies,
nurses constructed the position of an active and creative nurse by
flexibly applying organisational policies in practice (Fairclough,
2006).
Upon reflecting on video-recorded data, nurses made sugges-
tions to change their habitual activities involved in searching for
the controlled drug key. However, during field observations,
nurses demonstrated an acceptance of routine practice and work-
ing environment. By showing nurses0 difficulty in communicating
with each other about their needs for the controlled drug key on
video, video-reflexivity enabled nurses to think about and discuss
their daily practice, to reflect on ritualistic events, and to make
suggestions for practice change.
The main limitation of this study involves possible changes of
health professionals0 practice when being observed. To prevent
changes in health professionals0 behaviour and practice, the first
author spent a lot of time in the ward and built up rapport with
individual health professionals prior to data collection. During
data collection, the first author conversed with health profes-
sionals and patients at appropriate times to enhance trust and
understanding. In addition, we employed different data collection
methods in an effort to reveal inconsistencies in the data. Another
possible limitation involves the recruitment of individuals who
might have had an interest in medication communication activ-
ities. We encouraged health professionals of different positions
and levels of experience to participate in the study. As a result, we
were confident that our findings had represented a diversity of
perspectives and understandings of observed phenomena. We
only focused on the verbal form of medication communication
occurring in the ward space. The electronic, written and visual
forms of medication communication were not captured in
the study.
6. Conclusion
Using multiple data collection methods, we identified compet-
ing discourses in medication communication processes in the
ward physical environments. The discourse of task completion
was in constant tension with the discourse of patient–centred
interactions during medication activities. There were also tensions
arising from the enactment of improved technologies and the
implementation of them in clinical contexts. Opportunities should
be created for health professionals to discuss and reflect the
impact of ward environments on their medication interactions
with patients and how this impacts medication safety. Hospital
administrators and architects need to involve first-line health
professionals into future hospital design. The introduction of
new technologies should take account of the context of clinical
activities. For example, more medication retrieving devices can be
located in different corridors to meet high medication demands of
patients in medical wards.
Our findings also revealed working interruptions associated
with the use of mobile phones during medication communication
198 W. Liu et al. / Health & Place 26 (2014) 188–198
processes. Here we are not in a position to oppose communication
through mobile phones, knowing the moving nature of health
professionals during their clinical work. Nevertheless, we encou-
rage health professionals to consider the influence of their com-
munication behaviours on their working efficiency and on that of
others. Additional research on the effects of space and mobility on
clinical practice is required.
Acknowledgements
This study was funded by an Australian Research Council
Discovery Grant [grant number DP0879002]. The authors would
like to thank the staff members and patients who generously gave
up their time to participate in this study. The authors are grateful
to the anonymous reviewers for their constructive comments to
strengthen this paper.
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