Unveiling Implicit Rules: Exploring Hospital-Based Healthcare Provision for People Living with HIV Who Use Drugs

Background and Purpose: People living with HIV (PLWHIV) who use drugs are hospitalized more frequently than the general population and report experiencing suboptimal care. The clinical practice of healthcare providers directly shapes a patient’s hospital admission experience. However, limited research literature articulates the perspective of healthcare providers who deliver care to this population. This research examines the practical knowledge (i.e., beliefs and internalized rules that guide actions) of healthcare providers that impact the hospital admission experience of PLWHIV who use drugs. Two research questions guided this study:

1) How does healthcare providers’ practical knowledge influence the construction of PLWHIV who use the drug’s patient identity?

2) What rules do healthcare providers identify as influencing healthcare delivery during hospital admission of PLWHIV who use drugs?

Methods: Purposive sampling was used to recruit 26 interdisciplinary healthcare providers (i.e., social workers, physicians, nurses, dieticians, and pharmacists) who provide direct care to PLWHIV who used drugs while on inpatient wards at three large urban Canadian hospitals in Toronto and Ottawa. Participants completed a short demographic questionnaire prior to participating in a qualitative semi-structured interview; interviews were audio-recorded, transcribed verbatim, and uploaded into NVivo version 12 qualitative software to facilitate thematic analysis. Analysis of questionnaire data was completed using SPSS version 22. Structuration theory guided interpretation of results. Structuration theory allows for a focused exploration of the interconnectedness of agency and structure.

Results: Informing the healthcare providers’ practical knowledge is their professional lived experience, which constructs what healthcare providers consider to be an objective understanding of PLWHIV who use drugs’ health needs and informs implicit rules applied in their practice. For example, a change expected to occur during hospital admission (e.g., abstaining from drug use) is situated within the healthcare providers’ practical knowledge and is unknown to the patient unless experienced by way of implicit rules that guide clinical practice. The professional lived experience of interacting with patients who use drugs was acknowledged as being key to directing decision-making when delivering care to PLWHIV who use drugs. This professional lived-experience-informed understanding sometimes superseded current research evidence within the relevant literature. Relying on professional lived experience to guide clinical practice demonstrates a failure to acknowledge, or account for, actions guided by healthcare providers’ beliefs and internalized rules. Notably, most healthcare providers reported that professional lived experience guided their clinical practice more than their education and/or training.

Conclusions and Implications: Managing healthcare for complex populations, such as PLWHIV who use drugs, without explicit hospital rules, leads to the development of implicit rules that align with healthcare providers' practical knowledge. Reflexive monitoring, an approach used to surface beliefs and internalized rules, aids in deconstructing practical knowledge, thereby influencing the development of explicit rules and, in turn, the actions of healthcare providers. Explicit rules are valuable in directing training requirements, providing clarity on a best-practice approach, and ensuring accountability of all people in the hospital setting. Recommendations put forward in this study can be applied to improve the hospital admission experience of PLWHIV who use drugs.