Table 8. Representative quotations from Theme 6 reflecting ‘Reflective Motivation’ of the COM-B model.
| Theme 6. Lack of clarity regarding the roles and accountability | |||
|---|---|---|---|
| Subtheme | TDF Domains | Quotes (source) | Barrier or enabler? |
| The buck stops with the surgeon, ownership required | • Social/ professional role and identity • Beliefs about Capabilities • Beliefs about Consequences |
“Well, they (surgeons) are (responsible). And, part of the reason for that is because the buck stops with them when it all turns horrid… It’s ultimately theirs… There’s a reason why they get to make the call.” (F13, private pharmacist) | Barrier |
| “We’ve got a good thing in place at the moment where the anaesthetists are owning it intraoperatively, and, I think, postoperatively, it’s put back on to the teams, which is then where we see the major variance in practice.” (F12, public pharmacist) | Enabler | ||
| “I think someone needs to own it. So, I would say most hospitals… whether it’s the anaesthetist or surgeon, someone has to own it. If you give it to too many people, no one’s going to own it, and no one will do it. So, they need to have a champion. So, whether it’s anaesthetists in theatre… for us, here, it’s quite anaesthetic-driven. Which has been good.” (F12, public pharmacist) | Enabler | ||
| Passive prescribing hinders accountability and SAP cessation | “Most of the time, they’re (surgical consultants) not really aware of what their residents and registrars are charting.” (F10, public anaesthetist) | Barrier | |
| “But, most of the teams here, because they work together for so long, it is, you know, practice of what they’ve always done. So, I guess, it’s a conversation that they’ve (anaesthetists and surgeons) had previously, and it is assumed that that’s what they just keep going with.” (F11, private theatre nurse) | Barrier and enabler | ||
| “The default for the resident is to continue with the status quo until someone tells them it’s okay to stop. So, again, the pharmacist will often only get access to the resident, who won’t know what to do necessarily, and they’ll continue it as a default. It’s access to the senior decision-makers that is often the gap.” (F10, public anaesthetist) | Barrier | ||
| Capacity for role expansion of pharmacists and nurses. | “There is orthopaedic prophylaxis that is charted by the PAC pharmacists in pre-admission clinic, which is again very protocol driven…And, that includes any post-operative prophylaxis. I think, it’s a very collaborative model. (F12, public pharmacist) | Enabler | |
| We do rounds with the pharmacists…They question us about everything…They (pharmacists) are very helpful. (F9, public cardiothoracic surgeon) | Enabler | ||
| “A lot of the antibiotic decisions go over the pharmacists’ heads because they don’t have that real clinical insights as to the decisions that were made. I quite often have discussions with the pharmacists about why we’ve chosen antibiotics for plastics, for head and neck patients, and they just don’t have any understanding of, like the intraoral communication and what difference that makes…” (F14, public surgical resident/ registrar) | Barrier | ||
| “I think, nurses are much better at following guidelines…And, ward pharmacists. If there was a very clear statement around these (antibiotics)_ in the surgeries, that they should or shouldn’t (be prescribed), then they will flag that up” (F10, public anaesthetist) | Enabler | ||