Table 2.
Verbatim Quotes From Interview Transcripts to Illustrate and Validate the Themes That Emerged
| Theme | Quote Relevant to Theme | Quote in the Theme Relevant to Prescribing Etiquette |
|---|---|---|
| Decision-making autonomy | Q1 Very occasionally if I have a very strong feeling about the patient deteriorating, despite not any other markers suggesting of infection, I would definitely push my case [with infection specialists] to start antibiotics or make changes. —Senior Doctor, Pediatric Intensive Care (10 y) | Q4 I think doctor to doctor, it's very difficult for clinician to clinician, especially different specialties to go and criticize one another. I think that's not collegial practice, so people don't want to do that. —Nurse, Outpatient Parenteral Antimicrobial Therapy Services (14 y) |
| Q2 Sometimes during a procedure, if the surgeon feels there's a need to introduce antibiotics, they say so and I have never challenged that, no one has ever challenged that. —Nurse, Orthopedics (12 y) | Q5 … they [doctors] may have more information that I'm not yet aware of which may then mean that actually it is entirely appropriate. —Pharmacist, Medicines for the Elderly (4 y) | |
| Q3 Sometimes you come on the ward round and you realize that something's prescribed which you don't really understand. Not to say that your colleague's done something wrong but I always try and understand why that step's been taken. Whether there's something that I have missed or I have overlooked which is why this person's prescribed a different drug. —Senior Doctor, Pediatric Intensive Care (10 y) | Q6 Even if they're [visiting doctors] doing the wrong thing, which they do do sometimes, the intensive care consultant probably knows about it. So it's difficult for me to go and say you can't do this … —Pharmacist, Intensive Care Unit (7 y) | |
| Limitations of local evidence–based policies | Q7 There's no evidence base looking specifically at the immunosuppressed end-stage renal failure population. But my anecdotal experience is that they get sick very quickly and so for that reason I think for each individual patient it's a good antibiotic the long-term consequences of that, there's no evidence really to say … but I'm fully aware of the risks. —Specialist trainee Doctor, Renal Medicine (7 y) | Q11 But in reality you wouldn't, just because you have to get on with your senior colleagues and all your colleagues really. And so a more direct approach such as that, I just wouldn't—I would never question a consultant. —Junior Doctor, Accident and Emergency (2 y) |
| Q8 … you've got patients who don't actually fit in the guidelines and that's when it becomes difficult because you've got different consultants and different doctors willing to try different treatments, they have different opinions and then they kind of go with what they want, even if you refer them to infectious diseases they don't take things on board … —Pharmacist, General Medicine Training (2 y) | Q12 If I want to change something and I think it's appropriate that we just switch this as per policy, I might go straight to the registrar for example and find the time to, for them to get it changed. Rather than maybe the more junior doctor who may be reluctant because actually the consultant mentioned it on the ward round that they actually wanted a particular drug. —Pharmacist, Medicine for the Elderly (4 y) | |
| Q9 Sometimes it is difficult to … use the policy because the policy will be your average sort of thing, it's not looking at someone at the top or at the bottom. —Pharmacist, General Medicine (2 y) | Q13 I think that the current policy is rational. The decision was made by a subgroup within my specialty, composed of people whose judgment I respect and chaired by people whose judgment I respect and I'm very happy to comply with the decisions that they make. —Senior Doctor, Renal Medicine (32 y) | |
| Q10 I think everyone I work with and personally we're acutely aware of the issues of antibiotic resistance and that we do prescribe lots of broad-spectrum antibiotics. And we're aware of the implications of that … But it's that balance and there's unfortunately no real evidence base in our specific population with regards to what the best way forwards is. —Specialist Trainee Doctor, Renal Medicine (7 y) | Q14 I find sometimes doctors don't think sometimes that they need a policy to tell them what to prescribe. And that can make it difficult. Pharmacist, Medicines for the Elderly (4 y) | |
| So I find that when you explain the rationale for prescribing something and not the other, then you are listened to more. —Pharmacist, General Medicine (5 y) | Q15 …the problem is that different consultants would use different antibiotics. —Nurse, Vascular Surgery (8 y) | |
| You can tell like some consultants are just not interested in what [patients are] on whereas some consultants will ask if they're on antibiotics. So it varies a lot between consultants, I think if they all start feeding it down it will work. —Pharmacist, General Medicine (5 y)
I was very aware that I needed to stick to the guidelines because I'm quite likely to overstep them if I was left to my devices. And it's very variable. Some of the consultants in general medicine were quite pedantic about making sure that you stuck to the guidelines. —Specialist Trainee Doctor, Renal Medicine (7 y) |
The junior doctors tend to change it and the junior doctors won't change it if their senior doctors, if the consultant or registrar's specifically asked them to prescribe something else, in which case you can normally work out why and sometimes it's just that the reg wasn't sure of what to give, he's just said oh use this when they could have used something from the policy and get them to change it or you'll get cases where their specific consultants or regs want to use certain things that are outside policy. —Pharmacist, Intensive Care Unit (7 y) | |
| Culture of hierarchy | Q16 The junior doctors tend to change it and the junior doctors won't change it if their senior doctors, if the consultant or registrar's specifically asked them to prescribe something else … —Pharmacist, Intensive Care Unit (7 y) | Q19 The prescribing sometimes is very difficult because it's basically the junior doctor who does the prescribing and there is quite a lot of place for error because they take advice from us and they sometimes even ask how do you spell the drug. So they are prescribing something they have no idea about. I might be doing the prescription course next year, that would help because I could then take direct advice from the microbiologist and just do it myself, rather than phoning somebody else and getting a third person to prescribe. —Nurse, Intensive Care Unit (21 y) |
| Q17 That [micro ward rounds] was led by our lead clinician who felt very strongly about it and he met a like-minded microbiologist who also felt very strongly about it so they led on that and got that started. And now it's in our culture. —Nurse, Intensive Care Unit (19 y) | Q20 I think the nurses have a big influence, they say “oh no, we haven't got that in stock but we've got this, this is what we normally use.” —Pharmacist, Neonatal Medicine (40 y) | |
| Q18 Visiting consultants, they'll come with their team, an entourage of people with them. Obviously therefore they're role modelling to their team. So if they've got bad practice and it's not challenged then it's actually absorbed by all the people that are standing behind them who are consultants of the future. So you really do need to challenge. —Nurse, Intensive Care Unit (19 y) | Q21 I mean I think the junior doctors actually are sometimes quite glad to see us because they often want advice on what to do with … how to prescribe certain drugs because they often don't know, especially the brand-new qualified doctors … —Pharmacist, Respiratory Medicine (18 y) | |
| Yeah I would but I would probably challenge it at a higher level, ie, I would probably go back to our consultants and say one of the registrars has got a habit of just putting everybody on this and when I've talked to them about it doesn't seem to have any particular rationale except when they worked somewhere else that's what they did and I'm a bit concerned. —Nurse, Intensive Care Unit (19 y) | Q22 Because my experience of working on the wards here is that as a doctor you are very busy and you don't necessarily have time to do everything, so it is very useful to have other people who can ratify things, and they [pharmacists] do make valuable contributions and they are very good at kind of flagging up issues, particularly in terms of the escalation and stepping down and rationalizing when the time is right, making sure that kind of empirical prescriptions, broad spectrums aren't left for days and days at a time. —Specialist Trainee Doctor, Renal Medicine (7 years) | |
| The consultants rarely, they rarely prescribe for inpatients themselves because they'll always have a team of doctors with them so they'll make a suggestion on the ward round but it will be a junior doctor writing the drug out … —Pharmacist, Respiratory Medicine (18 y) | I think it goes from the top down so everybody has to do the same thing. If the consultant or registrar doesn't set a good example, the junior will certainly not follow it. —Specialist Trainee Doctor, Stroke (11 y) | |
| To be honest I don't go round checking the drug chart of 10 patients on the ward, to see they're on the right drugs. There isn't enough time in the day. I rely that people are sensible, that are following guidelines, that the pharmacist has checked them, the middle ranking doctor's checking them. Whilst it's my responsibility the patient has the right treatment, I don't have the time to check every detail of it. So I don't, to be honest I assume my patients are on the right treatment, I can't tell you they are, I haven't seen their drug charts. —Senior Doctor, Oncology (25 y) |