Table 4

Supporting quotations for contextual factors theme

SubthemeSupporting quotations
Decisions in-hours vs out-of-hours13. “Most antibiotic decisions are made by microbiology or the consultant rather than us. On the wards it’d be different, it’d be more us, but over here everything’s passed on to someone more senior.” —P27, early-career trainee, hospital 1, VBI
14. “I would like to use slightly less strong antibiotics, but I’m not allowed to. […] if you make the decision out-of-hours it’ll get changed back in-hours. It’s made by the consultants and they rely a lot on microbiology […] there’s very little independence in decision-making in an intensive care unit on a junior level.” —P35, middle-grade trainee, hospital 2, VBI
15. “[…] during the day, there’re lots of bosses around, and you’d get to phone up micro, and there’d be someone on the micro ward round. Then you might be helped, you know might… the consultant might take the decision to be…to hold steady, wait for a bit longer, wait for these results to come back. And then take a decision. But if it was just down to skeleton crew, a couple of SHOs [early-career trainees] and the Reg. [middle-grade trainee], in the middle of the night, three or four, after the consultant probably has gone to bed, the Reg. might take the decision that actually we’re just going to [prescribe antibiotics].” —P3, early-career trainee, hospital 1, VBI
16. “[…] you are always less likely to phone a consultant in the middle of the night for advice because you are more worried about disturbing them. […] It’s when you feel like you’re on your own and you can’t get it in touch with anyone else, that’s when I think you err on the side of caution and you prescribe [antibiotics].” —P25, middle-grade trainee, hospital 3, FG
17. “[…] out-of-hours or what have you, when you haven’t got all of the support around decision making that you might want, your primary aim is to do something which is safest for the patient in front of you […] [which] is to give them the broadest spectrum [antibiotic] you can at the time.” —P15, middle-grade trainee, hospital 3, VBI
Input from external teams18. “If you go on [Consultant Microbiologist]’s ward round and no one can, eh, say why the antibiotics, what it’s for, or when it’s going to stop, then that’s a good thing to challenge. And I think that probably has resulted in us shaving a few days of antibiotic usage and therefore, last year, achieving that [quality service initiative].” —P38, consultant, hospital 1, FG
19. “[…]micro base it [antibiotics] on the information they’re given by the registrars and their decision will be as good as the information that they get.”
P10, consultant, hospital 2, FG
20. “[Early-career and middle-grade trainees are] just happy to take opinions from other people and just do that and just say it was suggested by X, Y, and Z, and that’s why we’ve done it. So, I think we’ve actually lost our skills as clinicians […] If it’s something to do with nutrition, they say tell the dietician. If it’s something to do with antibiotics, tell the microbiologist.” —P8, consultant, hospital 4, VBI
21. “I don’t feel that confident about getting the right antibiotic. I’d want to get micro involved.” —P57, middle-grade trainee, hospital 3, VBI
22. “[…] it’s very rare that surgical prophylaxis will continue past 24 hours. There’s one particular gastro-intestinal surgeon who does five or seven days for his hepatectomies and stuff and try as we might we can’t get that stopped.” —P5, pharmacist, hospital 3, FG
23. “It’s a bit of a consensus, isn’t it? We try hard not to have a massive fight. We try and persuade people. I wouldn’t go up to a haematologist very often and insist they stopped all the antibiotics and say, well, even if you’re not, I’m going to. Well, you’re on my ward - that wouldn’t happen. It’s kind of well we think there’s no good reason, can we [stop antibiotics]?” —P48, consultant, hospital 1, FG
24. “Most of the time, we’re fighting off external pressure to change – to either crank up or put two antibiotics or start them inappropriately. We’ve got lots of physicians that seem to think that everybody needs an antibiotic when there’s [something] wrong with them which we’ll resist quite strongly.” —P29, consultant, hospital 4, FG
25. “[…] the trouble is if you stop the antibiotic on a haematology patient and something goes wrong, then you’re automatically in firing lines. So, I don’t think anybody does tend to.” —P17, microbiologist, hospital 1, FG
ICU prescribing norms

26. “[…] here, there’s been a lot more of a push to get a clearer idea of the source before you start [antibiotics].” —P44, middle-grade trainee, hospital 1, VBI
27. “[…] we’re really tightly controlled here for antibiotics. There isn’t much leeway. […] Co-amox [iclav] is in the corner [i.e., banned], we’re not allowed to touch it. […] You get a slap on the wrist if you deviate from the guidelines.” —P20, early-career trainee, hospital 4, VBI
28. “[In this ICU] the use of antibiotics is far more widespread and so you would be against the grain if you didn’t use them. So, you would be not part of normal practice.” —P54, middle-grade trainee, hospital 2, VBI
29. “For me, at least, I would like to stop as soon as possible, for every antibiotic, especially if it was given empirically. I think many times we just continue antibiotics when it’s [sic] uncalled for.” —P23, middle-grade trainee, hospital 2, VBI
30. “You have to go with your hospital protocol because it’s designed with your patient demographics in mind.” —P21, middle-grade trainee, hospital 3, VBI
31. “There are some guidelines but they’re not really go-to guidelines for intensive care as they are on AMU [acute medical unit] and throughout the hospital. I think they’re a bit looser. I think it’s more individually decided upon. On the ward there are guidelines, but they are pretty much everyone follows that line unless you’ve got something very unusual. Whereas on ICU it’s not like we have a set of guidelines that we generally go down that line.” —P51, consultant, hospital 1, FG
  • FG, focus group; ICU, intensive care unit; VBI, vignette-based interview.;