Trainee doctors’ experiences of common problems in the antibiotic prescribing process: an activity theory analysis of narrative data from UK hospitals

Abstract

IntroductionPrescribing antibiotics is an error-prone activity and one of the more challenging responsibilities for doctors in training. The nature and extent of challenges experienced by them at different stages of the antibiotic prescribing process are not well described, meaning that interventions may not target the most problematic areas.ObjectivesOur aim was to explore doctors in training experiences of common problems in the antibiotic prescribing process using cultural–historical activity theory (CHAT). Our research questions were as follows: What are the intended stages in the antibiotic prescribing process? What are the challenges and where in the prescribing process do these occur?MethodsWe developed a process model based on how antibiotic prescribing is intended to occur in a ‘typical’ National Health Service hospital in the UK. The model was first informed by literature and refined through consultation with practising healthcare professionals and medical educators. Then, drawing on CHAT, we analysed 33 doctors in training narratives of their antibiotic prescribing experiences to identify and interpret common problems in the process.ResultsOur analysis revealed five main disturbances commonly occurring during the antibiotic prescribing process: consultation challenges, lack of continuity, process variation, challenges in patient handover and partial loss of object. Our process model, with 31 stages and multiple practitioners, captures the complexity, inconsistency and unpredictability of the process. The model also highlights ‘hot spots’ in the process, which are the stages that doctors in training are most likely to have difficulty navigating.ConclusionsOur study widens the understanding of doctors in training prescribing experiences and development needs regarding the prescribing process. Our process model, identifying the common disturbances and hot spots in the process, can facilitate the development of antibiotic prescribing activities and the optimal design of interventions to support doctors in training.

Understanding surgical antimicrobial prescribing behaviour in the hospital setting: a systematic review and meta-ethnography protocol

“…Ethical approval is not required for a synthesis of published peer-reviewed studies (http://www.hra-decisiontools.org.uk/ethics/). We (HP, KM and NB) collaborated to prepare a National Institute for Health Research funding application with the intention to build on previous work [45,46] and this has now been funded. HP has worked as a National Health Service Hospital Pharmacist for the past 15 years, specialising in the eld of antimicrobials since 2009, and is now a National Institute for Health Research (NIHR) Clinical Doctoral Research Fellow.…”

Understanding Surgical Antimicrobial Prescribing Behaviour in the Hospital Setting: A Systematic Review and Meta-ethnography Protocol

“…We (HP, KM and NB) collaborated to prepare a National Institute for Health Research funding application with the intention to build on previous work [45,46] and this has now been funded. HP has worked as a National Health Service Hospital Pharmacist for the past 15 years, specialising in the eld of antimicrobials since 2009, and is now a National Institute for Health Research (NIHR) Clinical Doctoral Research Fellow.…”

How to … use qualitative research to change practice

“…Another way to facilitate practice change is the research‐assisted method called The Change Laboratory, which stems from activity theory, which has been used extensively to study workplace learning and increasingly also in medical education . Since the late 1990s, The Change Laboratory has been utilised successfully in health care research and development, to explain the current situation and the need for change.…”

“…Thus, the outcomes are designed by participants as they work out expansive solutions to the problems within their workplaces . However, the complexity of care processes and the uncertainty about outcomes can create frustration, ambiguities and further tensions amongst participants, which can also be challenging for the researcher to manage. In addition, both approaches described here investigate situated cases, and people experiencing particular critical situations, so the findings might not be directly transferrable to other social or organisational settings .…”

“…This involves paying attention to issues such as the professional boundaries between the different health professionals involved in care processes, which may have formed over a long time, since they may influence the process of delivering care. Increased attention also needs to be directed to the work and learning of health care students and trainees who often experience challenges within these complex environments . Acknowledging the possibility of unexpected consequences when attempting to change complex processes and practices also becomes important.…”