Table 9. Recommendations for change to optimise appropriate SAP decision-making and prescribing.

COM-B	Theme	Subtheme	Recommendations for change
Physical Capability	Low priority for surgical antimicrobial prophylaxis prescribing skills.	Surgical technique of greater importance	• Provide targeted education and training on principles for SAP and AMS as part of orientation training. • Increase surgeon engagement in SAP decision-making and prescribing.
		Deskilling surgeons
Psychological Capability	Prescriber autonomy overrules guideline compliance.	Guideline knowledge and awareness of limitations	• Continue to increase accessibility of guidelines in the operative setting. • Increase engagement of surgeons and anaesthetists in guideline development. • Mandate documentation for rationale of guideline deviation.
		Competition as a means to regulate behaviour	• Conduct and feedback SAP prescribing audit data to departmental heads to facilitate benchmarking at multiple levels—consultant, surgical unit, hospital, state.
Social Opportunity	Social codes of prescribing reinforce established practices	Intra-specialty Hierarchy Rules	• Target AMS interventions at senior surgical consultants. • Engage with senior surgical consultants for the development and implementation of quality improvement initiatives such as AMS.
		Cross-specialty prescriber etiquette
Physical Opportunity	Need for improved communication, documentation and data for action	Poor documentation and communication	• Promote standardisation of SAP workflow and documentation, specifically; - Indication for procedural and post- procedural SAP; - Duration of post-procedural SAP, and differentiation between SAP and antibiotics for treatment of actual infection; and - Details regarding antibiotic management in the hospital discharge summary for GPs and plans for re-referral. • Modify the ‘time-out’ process to include discussion of post-operative SAP. • Develop tailored clinical decision support systems and prompts for SAP.
		‘Time-Out’ supports pre-operative communication; post-operative management is less standardised
		Data for action	• Engage with surgeons to identify relevant quality indicators. • Support ongoing SAP prescribing audits. • Increase capacity for auditing of outcomes in relation to quality of SAP prescribing.
Automatic Motivation	Fears and perceptions of risk hinder appropriate SAP prescribing.	Fear of infections	• Collect local outcome data that supports evidence-based SAP, rather than prolonging SAP out of fear of infections. • Highlight the potential harms to the patient from inappropriate antibiotic use to promote AMS initiatives.
		Varied risk perceptions across specialties	• Tailor AMS interventions that are reflective of the surgical specialties’ niche risk perceptions, e.g., recommend alternative non-antibiotic creams and ointments post-plastic surgical procedures.
		Fear of litigation	• Gather support from hospitals at an executive/policy level to enable surgeons to prescribe evidence-based SAP. • Undertake further research into the impacts and influence of private health insurers on antimicrobial prescribing.
		Risking career progression and job security	• Increase awareness of current fears and issues facing junior surgeons. • Collaborate with existing programs such as the RACS action plan to build a ‘culture of respect’.
Reflective Motivation –	Lack of clarity regarding the roles and accountability	The buck stops with the surgeon, ownership required	• Promote collaboration between surgeons and anaesthetists for the development of a SAP pathway or workflow that defines both professionals’ roles pre-, intra- and post-operatively to increase role clarity and accountability for SAP. • Promote electronic prescribing and AMS workflow to support greater prescriber accountability.
		Passive prescribing hinders accountability and SAP cessation
		Capacity for role expansion of pharmacists and nurses.	• Development and training for emerging roles of nurse and pharmacist prescribers. • Development of Enhanced Recovery After Surgery (ERAS) pathways that include both pre and post-procedural SAP and AMS principles across the operative setting. • Partnered/collaborative SAP prescribing models