Uncomfortable prescribing decisions in hospitals: the impact of teamwork

Abstract

SummaryObjectives Prescribing is not always driven by therapeutic motives alone; social and intrinsic factors also play a part in the decision. However, most research into prescribing influences has been conducted in general practice, with very little conducted within hospitals. One potential influence is the hospital multidisciplinary team, yet little attention has been paid to how interactions between teams and team members may influence prescribing. This study investigated the effect that team interaction and structure had upon UK hospital doctors' prescribing decisions, particularly their discomfort felt prescribing. Design and settingThe study used the critical incident technique and in-depth interviews. Prior to an in-depth interview, 48 doctors of varying grades from four hospitals were asked to remember any uncomfortable prescribing decisions that they had recently made. These 'incidents' were discussed in depth. All interviews were tape-recorded and transcribed verbatim. A grounded theory approach to data analysis was taken.Results There were 193 critical incidents described in the interviews. Over one-third were related to the difficulties of prescribing within a team environment. Discomfort frequently arose because of factors relating to the hierarchical structure; in particular, junior doctors described their discomfort when they were uncertain of seniors' prescribing decisions. Prescribers also adhered to rules of prescribing etiquette, including the maintenance of other doctors'/teams' prescribing decisions and adherence to prescribing norms. Discomfort also arose from a perceived pressure to prescribe from the nursing team. Doctors admitted to prescribing to maintain overall team relationships, sometimes ignoring hospital regulations and best practice to do so. ConclusionOverall, this study demonstrated that hospital doctors' prescribing decisions were strongly influenced by relationships with other team members, particularly nurses and senior doctors. Ways of reducing this discomfort should be explored and further research is advocated in this area.

Cultures of resistance? A Bourdieusian analysis of doctors' antibiotic prescribing

“…As illustrated by social scientists previously, antibiotic use can be inflected by patient expectations for care (Lewis & Tully, 2009;Stivers, 2005;Stivers et al, 2003). In nonhospital settings, antibiotic use has been shown to be deeply embedded in doctor-patient talk within medical consultations, including being shaped by the use of power/capital and performances of medical expertise.…”

“…Lewis & Tully, 2009). This includes the relationships between doctors in the form of norms and hierarchies (Britten, 2001;Charani et al, 2013;Lewis & Tully, 2009;Hulscher et al, 2010) as well as relations with patients and their families (Stivers, 2005). Analysis thus far has largely focused on primary care settings (e.g.…”

“…[Non-consultant, General Medicine, Male] Families introduced an additional variable on top of patient expectations for "something to be done" and the pressure to perform the benevolent role (Lewis & Tully, 2009). The capacity to watch and wait was lessoned.…”

“…The principles and dispositions which make up habitus prepare doctors to cope with unforeseen, time-limited and ever-changing situations. Such principles within the hospital prioritise individual patient care (the practical) and professional credibility over the threat of resistance (the abstract) (Lewis & Tully, 2009). As such, while there may be costs associated with the current principles within the field, the costs of countering principles such as benevolence, immediate patient wellbeing and clinical M A N U S C R I P T…”

A sociological exploration of the tensions related to interprofessional collaboration in acute-care discharge planning

“…However, research from other health care contexts shows that other health care providers can 'resist' medical dominance (Lewis & Tully, 2009;Liu, Manias & Gerdtz, 2013).…”