Overall, 12,256 possible references were identified (Fig. 1). Eighteen qualitative papers met our inclusion criteria. Following quality appraisal (Table 3), three papers were excluded due to low quality of their reporting [29–31]. Fifteen papers reporting findings from thirteen studies were finally included in the synthesis [32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46].
Table 3
CASP Quality Appraisal (insert on page 12, line no 279)
Paper
|
Decision to retain for Phases 4–6
|
1.
Clear research aims
|
2.
Qualitative methodology appropriate
|
3.
Research design
|
4.
Recruitment strategy
|
5.
Data Collection
|
6.
Reflexivity
|
7.
Ethical Issues
|
8.
Data Analysis
|
9.
Findings
|
10.
Research Value
|
R1*
|
R2*
|
R1
|
R2
|
R1
|
R2
|
R1
|
R2
|
R1
|
R1
|
R1
|
R2
|
R1
|
R2
|
R1
|
R2
|
R1
|
R2
|
R1
|
R2
|
Almatar et a.l 2014 [29]
|
✘
|
Yes
|
Yes
|
Yes
|
Yes
|
P
|
Yes
|
P
|
Yes
|
Yes
|
Yes
|
No
|
No
|
Yes
|
Yes
|
U
|
U
|
Yes
|
Yes
|
P
|
Yes
|
Almatar 2015 [30]
|
✘
|
This is a thesis and is a copy of the above study [29].
|
Barlow et al. 2008 [31]
|
✘
|
P
|
P
|
P
|
Yes
|
P
|
P
|
Yes
|
Yes
|
P
|
Yes
|
No
|
No
|
P
|
P
|
No
|
No
|
P
|
Yes
|
P
|
P
|
Cortoos et a.l 2008 [32]
|
✓
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
P
|
P
|
P
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Bjorkman et al. 2010 [33]
|
✓
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
No
|
P
|
P
|
P
|
P
|
P
|
Yes
|
P
|
P
|
Broom et al. 2014 [34]
|
✓
|
P
|
P
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
P
|
P
|
P
|
P
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Mattick et al. 2014 [35]
|
✓
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
P
|
P
|
P
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
May et al. 2014 [36]
|
✓
|
Yes
|
Yes
|
Yes
|
Yes
|
P
|
Yes
|
Yes
|
Yes
|
P
|
P
|
No
|
No
|
P
|
P
|
U
|
U
|
Yes
|
Yes
|
Yes
|
Yes
|
Livorsi et al. 2015 [37]
|
✓
|
Yes
|
Yes
|
Yes
|
Yes
|
P
|
Yes
|
P
|
P
|
Yes
|
Yes
|
No
|
P
|
P
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
P
|
Yes
|
Livorsi et al. 2016 [38]
|
✓
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
P
|
P
|
P
|
P
|
P
|
P
|
P
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Skodvin et al. 2015 [39]
|
✓
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
P
|
P
|
Yes
|
P
|
Yes
|
Yes
|
Yes
|
P
|
P
|
Broom et al. 2016a [40]
|
✓
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
P
|
P
|
Yes
|
Yes
|
P
|
P
|
P
|
P
|
P
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Broom et al. 2016b [41]
|
✓
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
P
|
P
|
No
|
P
|
P
|
P
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Broom et al. 2016c [42]
|
✓
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
No
|
P
|
P
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Eyer et al. 2016 [43]
|
✓
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
P
|
P
|
No
|
P
|
P
|
P
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Rawson et al. 2016 [44]
|
✓
|
Yes
|
Yes
|
Yes
|
Yes
|
P
|
P
|
Yes
|
Yes
|
P
|
P
|
Yes
|
P
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Broom et al. 2017 [45]
|
✓
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
No
|
P
|
P
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Sedrak et al. 2017 [46]
|
✓
|
Yes
|
Yes
|
Yes
|
Yes
|
P
|
Yes
|
Yes
|
Yes
|
P
|
Yes
|
Yes
|
P
|
P
|
Yes
|
P
|
P
|
Yes
|
Yes
|
Yes
|
Yes
|
Key: *R1 – reviewer 1; R2 – reviewer 2.
Individual decisions: P- Partially, U- Unable to determine.
|
The included studies were from seven countries across three continents: Australia [34, 42, 45, 46], USA [36–38] and Europe, including the UK [35, 40, 41, 44], Belgium [32], Sweden [33], Switzerland [43] and Norway [39]. Studies were conducted in 41 acute hospitals, including private and public, tertiary and secondary care, teaching and non-teaching hospitals. The papers reported the experience of 336 doctors practising across various disciplines from a range of medical and surgical fields. All except three studies [36, 43, 44] provided gender information that included 274 participants, from which 106 (39%) were women. Not all authors provided details of their study context and it was not always possible to determine participants` ethnicity, specialty, length of clinical experience, and exact area of medical expertise. Most studies specified participants` level of experience representing a range of seniority (n = 14), whilst one study focused specifically on junior (foundation year) doctors [35]. The age of participants ranged between 20 [35] and 70 years [33].
Sample size varied considerably, from 10 [46] to 64 doctors [45]. Data were collected using individual interviews (n = 13) [33–35, 37–46], focus groups (n = 1) [32] and a mixed-methods approach comprising an online survey and semi-structured interviews followed by an observational study (n = 1) [36]. Overall, the studies had an acceptable methodological quality. However, most studies neglected the value of reflexivity (n = 12), with only three studies reporting how the authors` social background, location, role and assumptions may have affected the research process and findings [39, 44, 46].
Characteristics of the 15 papers, including author, year of publication, country/setting, study focus, population, data collection, analytic approach and key findings, are detailed in Table 4.
Table 4
Summary of qualitative papers included in the synthesis (insert on page 14, line no 312)
Study
|
Aim(s)
|
Sample
|
Data collection &
analysis
|
Key findings
|
Cortoos et al. 2008 [32]
Belgium
|
To determine the opinions and problems concerning the use of a local antibiotic hospital guideline.
|
1 tertiary care university teaching hospital
22 physicians from internal medicine (7 residents/ 6 staff) and surgery (6 residents/ 3 staff).
Ages: 26–60, 5 females/17 males.
|
Focus Groups
Framework Analysis
|
7 themes reported:
General attitudes and guideline interpretation;
guideline familiarity and awareness; guideline contents and agreement; social influence; multidisciplinary approach, organizational constraints; attitudes about specific interventions.
|
Bjorkman et al. 2010 [33]
Sweden
|
To explore and describe perceptions of antibiotic prescribing among Swedish hospital physicians.
|
7 acute hospitals
20 hospital physicians (5 urology physicians, 5 from surgery, 10 from internal medicine).
Ages: 31–70, 5 females/15 males.
|
Semi-structured Interviews
Phenomenographic Analysis
|
5 main categories of perceptions of hospital antibiotic prescribing and AMR:
Prefer “effective” treatment; too uncertain to be restrictive; stuck in the healthcare system; aware and restrictive, but support required; aware, interested and competent.
|
Broom et al. 2014 [34]
Australia
|
To investigate the experiences of doctors who prescribe antibiotics.
|
1 acute hospital
30 doctors from: emergency medicine (3), general medicine (4), geriatrics (3), intensive care (2), obstetrics and gynaecology (3), oncology (2), orthopaedics (2), paediatrics (1), renal medicine (2), sexual health (1), surgery (2), urology (1) and infectious diseases (4). House officers (4), registrars (7), advanced trainees (2), consultants/ staff specialists (11), consultants/ senior staff specialists (5).
9 females/21 males.
|
Semi-structured Interviews
Thematic Analysis
|
6 main themes reported:
Everyday sensitivity toward resistance; risk, fear and uncertainty; time, pressure and uncertainty; benevolence and the emotional prerogative; habitus and the internalisation of peer practice norms; hierarchies and the localisation of antibiotic prescribing.
|
Mattick et al. 2014 [35]
UK (England & Scotland)
|
To explore the antimicrobial prescribing experiences of foundation year (FY) doctors.
|
2 acute hospitals
33 junior doctors (21 FY1 and 12 FY2) working in medical and surgical wards.
Ages: 20–35, 18 females/15 males.
|
Narrative Interviews
Framework Analysis
|
6 overarching themes reported:
Personal incident narratives about antimicrobial prescribing; antimicrobial prescribing experiences; systems issues; working relations; educational experiences and needs; process-related data.
|
May et al. 2014 [36]
USA
|
To explore current practices and decision-making regarding antimicrobial prescribing among Emergency Department (ED) clinical clinicians.
|
8 acute hospitals
21 clinicians (attending physicians, residents, and mid-level clinicians with at least 2 years of ED experience).
|
Semi-structured Interviews (mixed-methods study)
Thematic Analysis
|
5 overarching themes reported:
Resource and environmental factors that affect care; access to and quality of care received outside of the ED consult; patient-provider relationship; clinical inertia; local knowledge generation
|
Livorsi et al. 2015 [37]
USA
|
To understand the professional and psychological factors that influence physician antibiotic prescribing habits in the inpatient setting.
|
2 acute hospitals
30 inpatient physicians: 10 physicians-in-training (8 internal medicine, 2 internal medicine/paediatrics) & 20 supervisory staff (17 hospital medicine, 3 pulmonary/critical care).
10 female/20 males
|
Semi-structured Interviews
Thematic Analysis
|
4 themes reported:
Antibiotic over-use is recognised but generally accepted; the potential adverse effects of antibiotics have a limited influence on physicians' decision-making; physicians-in-training are strongly influenced by the antibiotic prescribing behaviour of their supervisors; reluctance to provide critique, feedback or advice.
|
Livorsi et al. 2016 [38]
USA
|
To assess physician knowledge and acceptance of antibiotic-prescribing guidelines through the use of case vignettes.
|
2 acute hospitals
30 inpatient physicians: 10 physicians-in-training (8 internal medicine, 2 internal medicine/paediatrics) & 20 supervisory staff (17 hospital medicine, 3 pulmonary/critical care).
10 female/20 males
|
Semi-structured Interviews
Thematic Analysis
|
3 major themes reported:
Lack of awareness of specific guideline recommendations; tension between adhering to guidelines and the desire to individualise patient care; scepticism of certain guideline recommendations.
|
Skodvin et al. 2015 [39]
Norway
|
To investigate factors influencing antimicrobial prescribing practices among hospital doctors.
|
13 acute hospitals
15 doctors from five major medical fields (internal medicine (4), surgery (4), infectious diseases specialists (2), other medical field: oncology, neurology and intensive care), Interns/residents/consultants 2/5/8.
Ages: 25–65, 8 females/7 males.
|
Semi-structured Interviews
Thematic Analysis
|
6 major themes reported:
Colleagues; microbiology; national guideline; training; patient assessment; leadership.
|
Broom et al. 2016a [40]
UK
|
To identify why inappropriate prescribing trends continue.
|
1 teaching hospital
20 doctors: 8 consultant, 12 non-consultants from medical (15) and surgical specialty (5).
9 females /11 males.
|
Semi-structured Interviews
Framework Analysis
|
3 major themes reported:
Consumerism and complaints culture; priorities, team dynamics and the medical hierarchy; mythical properties of intravenous antibiotics.
|
Broom et al. 2016b [41]
UK
|
To explore doctors` experiences of antibiotic prescribing, and the role of social and institutional factors in influencing the decision-making process.
|
1 teaching hospital
20 doctors: 8 consultant, 12 non-consultants from medical (15) and surgical specialty (5).
9 females /11 males.
|
Semi-structured Interviews
Framework Analysis
|
3 major themes reported:
Negotiating multiple masters; junior doctors ‘stuck in the middle’ between infectious diseases, clinical microbiology and their supervising team; the dynamics of laboratory vs clinical medicine; the transmission of habit: evidence confronts mentoring, anecdote and experiential learning.
|
Broom et al. 2016c [42]
Australia
|
To explore the potential social dynamics underpinning doctors` antibiotic use and infection management practices.
|
1 acute hospital
30 doctors from emergency medicine (3), general medicine (4), geriatrics (3), intensive care (2), obstetrics and gynaecology (3), oncology (2), orthopaedics (2), paediatrics (1), renal medicine (2), sexual health (1), surgery (2), urology (1) and infectious diseases (4). Sample included house officers, registrars, advanced trainees, consultants/staff specialists and consultants/senior staff specialists.
9 females /21 males.
|
Semi-structured Interviews
Thematic Analysis
|
4 main themes reported:
Contesting `best` practice: risk and ambivalence; `fear of losing them` and the role of patient vulnerability; intra-professional and workplace context; `craft groups` and the perpetuation of localised norms.
|
Eyer et al. 2016 [43]
Switzerland
|
To determine reasons for using antibiotics to treat asymptomatic bacteruria in the absence of a treatment indication.
|
1 tertiary care hospital
21 general medicine physicians: 12 residents/9 senior physicians.
No gender documented.
|
Semi-structured Interviews
Thematic Analysis
|
5 main themes reported:
Treatment of laboratory results without considering the clinical picture; physician-centred factors; external factors; lack of attention to detail or analytical thinking, particularly under time constraints; overtreatment due to trivialization of urinary tract infection.
|
Rawson et al. 2016 [44]
UK
|
To map out and compare the decision-making processes employed for acute infection management on the hospital wards by non-infection medical specialties and explore any factors that influenced this process.
|
1 acute hospital
20 physicians (9 consultants, 4 registrars, 2 trainees, 5 junior doctors) from non-infection medical specialties (general internal medicine, such as cardiology, respiratory, and geriatric medicine) and augmented care specialties (haematology and nephrology).
No gender documented.
|
Semi-structured Interviews
Grounded Theory
|
3 overarching themes reported:
Mapping the decision-making process; factors influencing the decision-making process; windows of influence on decision making.
|
Broom et al. 2017 [45]
Australia
|
To examine how hospital doctors balance competing concerns around antibiotic use and resistance.
|
2 teaching hospitals
64 doctors from anaesthetics, emergency, geriatrics, gynaecology, haematology, ICU, infectious diseases, nephrology, oncology, orthopaedics, paediatrics, palliative care, respiratory, sexual health, and surgery.
27 junior doctors, 37consultants.
28 females/36 males.
|
Semi-structured
Interviews
Framework Analysis
|
2 key themes:
The significance of resistance for the hospital and the role of doctor in perpetuating resistance; overprescribing; easier and without perceived immediate risk.
|
Sedrak et al. 2017 [46]
Australia
|
To elucidate potential barriers and enablers to the adherence to antibiotic guidelines by clinicians treating community-acquired pneumonia.
|
1 acute hospital
10 clinicians from emergency medicine (4), general medicine (4) and infectious disease (2). 5 registrars and 5 consultants.
5 females/5 males.
|
Semi-structured Interviews
Thematic Analysis
|
3 main categories reported:
Knowledge, including familiarity with guidelines; attitudes, including confidence in antibiotic guidelines; behaviour, including documentation and communication, experience and clinical judgement.
|
Studies related (Phase 4) by their focus into two clusters:
Cluster A – studies that focused on the adherence to antimicrobial guidelines, including the barriers and enablers to uptake and the suboptimal use [32, 38, 46].
Cluster B - studies describing the experience of antibiotic prescribing with differing levels of emphasis placed on the influences on the prescribers` behaviour, ranging from the drivers of antibiotics prescribing, clinical decision-making to awareness of AMR [33, 34, 35, 36, 37, 39, 40, 41, 42, 43, 44, 45].
A 142 concepts across clusters A and B emerged with a resulting 17 higher conceptual categories (HCCs) or `piles` that shared meaning. The reported concepts within each conceptual category are detailed in Additional file 2. From these concepts and HCC, four overarching themes were identified during study translation (Phase 5): (1) Loss of ownership of prescribing decisions, (2) Tension between individual care and broader public health concerns, (3) Evidence-based practice versus bedside medicine, and (4) Diverse priorities between different clinical teams. Themes 1–3 were derived from reciprocal translation (findings were compatible). Theme 4 arose from refutational analysis when it was noted that some translated findings described alternative dissonant perspectives of the same phenomenon. Themes are presented below with narrative exemplars in Additional file 3.
1. Loss of ownership of prescribing decisions
Many hospital healthcare professionals have a role in antimicrobial stewardship but, overall responsibility for antibiotic decisions lies with prescribing clinicians. Many decisions are made by senior clinicians and then enacted by junior doctors. However, during nights and weekends, this arrangement shifts, and junior doctors are often expected to manage complex cases alone and make decisions to prescribe antibiotics on behalf of their senior colleagues, with limited support and feedback available at the time [34, 35, 36, 37, 38, 39, 40, 42, 44, 46].
When care delivery happens ‘out-of-hours’, the allocation of prescribing responsibility becomes ambiguous. Although junior doctors are expected to initiate or escalate antibiotics, they are hesitant to question or change decisions of their senior colleagues consequently reporting feelings of disempowerment [35, 41, 42, 44]. De-escalating or stopping treatments is considered a senior medical decision-maker role as this requires professional confidence and experienced clinical judgement. Making an independent clinical judgement is viewed by less experienced doctors as unrealistic, or `something of a dark art’ [42], highlighting variation in the perceived responsibility for prescribing decisions.
Patients transitioning between hospital wards means that the provision of care takes place in multiple hospital locations and across various professional groups, adding to the complexity. Doctors` rotations, rapid ward rounds, numbers of staff delivering care and patients being cared for `remotely` from their primary medical team compounds the problem, leading to frustration, anxiety and ultimately distancing from engaging with decision-making [33, 35, 36, 37, 39, 40, 43, 44]. Lack of awareness of what ultimately happens to the patient and whether the prescribed antibiotic therapy was the correct choice for the patient denies junior doctors the opportunity to learn from occasions when their prescribing decisions had been over-ruled or changed.
There was also a concern that some information handed over to the next shift (or clinical area) is not always acted on and prescribed antibiotics are not reviewed by the subsequent clinical team taking over a patient’s care. Fast-paced clinical environments, error-prone handovers, disjointed information and cumbersome IT systems present further challenges [32, 33, 34, 35, 36, 37, 39, 40, 42, 43, 44, 46]. Three studies highlighted that poor documentation of decisions and inconsistencies in monitoring and treatment plans compounded the problem and created a sense of anonymity or `invisibility` of decisions [35, 41, 44]. When reasons for antibiotic prescriptions in clinical patient notes are not documented, clear or easy-to-find, clinicians have to guess whether initial decisions regarding antibiotic choice and rationale was accurate and justified. This incomplete patient information impacts on clinicians` ability to take ownership of antibiotic prescribing decisions.
2. Tension between individual care and broader public health concerns
In uncertain clinical situations, doctors must make decisions in the presence of multiple and often conflicting objectives. While the ethical principle of a `good doctor` is to make decisions based on what is best for the individual patient [34], at the same time, clinicians have a responsibility to consider population-level consequences of overprescribing. On one hand, antibiotic overprescribing is recognised as a serious global concern but, on the other hand, not treating an infection may lead to serious patient complications, even death [33, 34, 37, 40, 42, 43, 44, 45], and loss of professional reputation. The abstract reality of future AMR causes internal conflict for the treating clinician facing the concrete reality of the ‘here and now’ - the patient`s clinical status and perhaps pressure from family and patients to ‘do something’. The short-term individual costs (for patients and professionals) have to be constantly weighed up against longer-terms societal gains.
Although clinicians consider AMR and its potentially severe consequences when choosing treatment, the threat of resistance is generally perceived to be a distant or not immediate issue [33, 34, 37, 42, 45]. With the exception of clinicians working within infectious diseases and microbiology departments [33], most participants appeared to downgrade the importance of the problem and its potentially devastating consequences during their prescribing decision-making process. Long-term effects of resistance at the wider community-level are not prioritised, and some degree of overuse of antibiotics to manage immediate patient risks is considered to be allowed and socially acceptable [33, 34, 37, 40, 45].
The risks of over-prescribing to the individual patient tend to be disregarded [45]. Some clinicians consider antibiotics a `peripheral thing’, of `limited concern` [34] with the threat of AMR as a theoretical problem, which morally and professionally important is not necessarily practical [33, 37, 40, 42, 45]. Recognition that individual practice contributes to the emergence of AMR is generally low and some clinicians are `desensitised` to the problem [45]. Absence of feedback on juniors` antibiotic prescribing limits the opportunity to identify reasons for the knowledge deficits and improve prescribing practice.
3. Evidence-based practice versus bedside medicine
Internal reasoning, or the way clinicians make sense of their decisions, plays a significant role in antibiotic prescribing. Prescribing behaviour, which may at first appear as `non-rational` or at odds with the evidence, is in fact a realistic and logical choice at the bedside, where positive patient outcomes, maintaining professional reputation and approval from supervisors take a priority [33, 34, 35, 36, 37, 41, 42, 43, 44, 45]. The health of individual patients lies at the core of medical professionalism and forms part of their professional identity. Being seen by the patient and/or relatives to be `doing good` drives clinicians to prescribe antibiotics for their patient regardless of whether it is evidence-based or not [44]. This internalised logic of over-prescribing is driven by the desire to improve patient condition(s) or at least provide a `beacon of hope` [43]. This rationale interplays with the expectations of never missing a diagnosis. Prescribing antibiotic treatment is seen a confirmation that at least something has been done [38].
In busy hospital environments, professional competence is being constantly evaluated. Decisions about whether to prescribe antibiotics are heavily influenced by fear of consequences for prescribers. Missing a potentially treatable infection could result in serious patient harm. Administering antibiotics or prolonging their use creates a perception of an emotional safety net [33, 34, 36, 37, 38, 39, 40, 42, 43, 44, 45, 46]. Although experience helps to identify and treat the severely ill patients, `erring on the side of caution` and prescribing antibiotics `just in case` provides reassurance and is therefore the default option irrespective of grade or experience [37].
Junior doctors report experiences of being criticised and seen by colleagues as incompetent when deciding not to treat [35, 37, 40, 42, 45]; in contrast, conservative antibiotic decision-making is rarely recognised as good practice [43]. Senior doctors’ preferences, expectations and prescribing habits also influence junior doctors’ prescribing decisions. Junior doctors risk facing social disapproval if their decision not to prescribe is at odds with the `social norms` of the hospital [34].
Expectations of patients` families and the developing `consumerism culture` pose additional pressure [40], resulting in a low threshold for prescribing antibiotics [33, 34, 36, 37, 39, 41, 42, 43, 45, 46]. Fear of patient complaints and potential lawsuit drives clinicians to adopting defensive medicine approaches and prescribe broad-spectrum antibiotics.
Prescribing according to guidelines offers some reassurance and protection, provided these are evidence-based, up-to-date, easily available and accessible and that doctors have time to consult them [32, 33, 34, 37, 38, 39, 41, 43, 44, 46]. Digressing from antibiotic guidelines is rationalised by the potential discrepancies between guidelines and practice. When the individual case of a patient does not `fit` readily into guidelines, clinical judgement must be applied [32, 35, 38, 41, 46].
4. Diverse priorities between different clinical teams
Multidisciplinary input is essential during hospital in-patient care. However, a multitude of experts are involved in patient care, with different tasks or interventions performed by different professionals, who may have different goals for the patient, which can result in variation of care, including antibiotic use. For instance, diverse priorities are evident in the weighting given to different phases of the antibiotic decision-making process between speciality groups. Despite a common overall approach, emergency department (ED) clinicians and surgical specialities emphasise immediate patient care and infection prevention including initiating antibiotics [32, 36, 40, 45, 46], whilst medical specialities focus on longer-term infection management concerns, including refining/reviewing of initial prescribing decisions and stopping antibiotics [41, 43, 44].
Heightened awareness of sepsis and associated risks and complications culminates in an urgency for surgeons and ED clinicians to commence antibiotics as soon as possible in anyone suspected of having an infection [36, 39]. By contrast, acute care medicine doctors report a common stepwise approach to the decision process surrounding acute infection management, whereby new information is constantly considered in the context of prior knowledge [44] and the use of microbiology test results when selecting antimicrobial therapy is emphasised. Within the same hospital, different clinical teams can have diverging opinions on, and requirements from, guideline content. For example, whilst surgical groups describe a strict interpretation of antibiotic guidelines [32], internal medicine doctors highlight that guidelines are incomplete by promoting a standardised, `one-size fits all` approach to antibiotic prescribing [36, 38, 39, 41, 44, 46].
Most clinicians (both genders and across settings) recognise the benefits of collaboration, including the availability of a second opinion in the treatment of infections and the support for the improved use of antibiotic prescribing guidelines. However, junior doctors experience difficulties in negotiating prescribing decisions with multiple authoritative figures from across various clinical teams [34, 35, 41, 44]. Effective collaboration and senior support were perceived by junior doctors as key facilitators in remedying deficiencies in practical knowledge of appropriate antibiotic prescribing [33–35, 38–40, 42–44].
Key professional collaborators identified in antibiotic prescribing were microbiology, infectious disease specialists and pharmacy. Infection diseases specialists were recognised as helping hospital doctors in AMR prevention by promoting and encouraging the use of guidelines and appropriate narrow-spectrum antimicrobials during handover meetings and ward rounds [33, 39]. Clinical microbiology colleagues were reported as acting as an important communication channel in infection management [35, 39, 44]. Medical doctors especially described. their services and advice as valuable and convenient to access. Although these experts were generally highly approved across medical and surgical fields, the relationship with them varied significantly depending on individual clinicians` interest in infectious diseases [32, 33, 35, 41, 45].
The presence of ward clinical pharmacists generated conflicting opinions. Most clinicians from medical and surgical groups (mostly male representing different levels of seniority) described pharmacists as helpful in discussing and sharing rationales for antibiotic prescriptions and prompting antibiotic review and de-escalation [37, 40, 44]. However, they were perceived by some participants (mostly male physicians from internal medicine) as interference [32].
Line-of-argument synthesis
From translation of findings across the 15 studies, a new line-of-argument emerged. This final stage in the process of meta-ethnographic analysis (Phase 6) enabled us to develop a higher order interpretation, that is, to generate a conceptual model drawn from, `but more than the sum of`, the final themes [21]. Through team reflection and by revisiting the original studies, it gradually became apparent that the four overarching themes overlapped and a more complex nuanced interaction between two micro- and macro-level dimensions of hospital antibiotic prescribing emerged. These two dimensions constantly and simultaneously interacted with each other producing multiple tensions for prescribers and formed the basis for our conceptual model (Fig. 2).
The model illustrates the multidimensional nature of hospital antibiotic decision-making and reflects the array of pressures and dilemmas which need balanced by clinicians as they decide their prescribing action(s). This multidimensional nature of antibiotic decision-making describes a complex dynamic and for every clinician, there will be a degree of interdependence between different factors influencing prescribing practice depending on their level of expertise and ability to tolerate risks for their patient and themselves. The illustrated elements, or factors, will form independent components on one level. However, they are not separate or discreet but constitute an integral part of a whole and will therefore exert a degree of direct or indirect influence on prescribing decisions. These elements coexist, interact and create a constant dynamic. Both macro (wider social structures, including the norms, standards, social and organisational constraints for human behaviour) and micro (individual behaviours) dimensions feature a complex interplay of influence, authority and the pursuit of treatment goals. The macro-level structures of hospitals provide the social and cultural setting for healthcare professionals to relate to each other, constantly shaping and influencing micro‐level dimensions that drives individual behaviours and everyday practice.
This unique and evolving dynamic results in the creation of micro-structures of influence, such as internalised logic of prescribing that underpins antibiotic use and drives social interaction with colleagues and patients. An understanding of these contextual drivers of overuse on both macro- and micro-level is fundamental to the development of sustainable interventions to optimise antibiotic use by hospital doctors.