Table 2 Facilitators and barriers to implementing a delayed prescribing intervention based on the Theoretical Domains Framework
Domain | Sub-category | GP quote | Pharmacist quote | Public quote |
|---|---|---|---|---|
Knowledge: an awareness of the existence of something | ||||
Facilitators | Knowledge about delayed prescribing | “It [delayed prescribing] is when you give the patient an antibiotic script and ask them to wait until they get bacterial symptoms before filling it.” (GP19) | “Is it [delayed prescribing] when the GP doesn’t give an antibiotic straight away and the patient needs to return for review?” (Ph14) | “The GP said it’s [sore throat] going to go like this for the next few days and that’s fine – don’t fill the script but if it gets to this, then go get the script filled or come back and see me.” (Pt03) |
Knowledge of symptomatic management | “I usually say simple analgesia” (GP04) | “I would suggest medication for symptomatic management…rest, good food, fluids…”(Ph10) | “Plenty of rest, fluids, Panadol” (Pt 04) | |
Knowledge that antibiotic use causes antibiotic resistance | “In my clinical lifetime we are going to be back to people dying of pneumonia and it is likely it we will have nasty resistant bugs that are going to come through and we will have no more antibiotics.” (GP04) | “But it’s [antibiotic resistance] got really bad now – with all these superbugs”(Ph06) | “I know there is more and more resistance to antibiotics and this is becoming an issue, especially if people don’t take their antibiotics properly and then the bugs mutate, and it goes on and on.” (Pt07) | |
Knowledge of when to start antibiotics | “…but if they [patients] know the symptoms on what to look out for, then they can get started on them straight away and see how they go with it” (GP18) | “If the GP discusses it [the illness] with the patient and lets them know that they don’t have an infection yet and if it does develop in a few days and explains it correctly…” (Ph07) | “I probably need to know what to watch out for in case it was getting any worse. Then I would need to know what to do next. So, what’s the point [I need] to [start to] worry?” (Pt12) | |
Barriers | Lack of knowledge about delayed prescribing | “…it’s more about bringing them [patients] back in few days to see the progression of the illness…” (GP02) | “I don’t know much [about delayed prescribing]” (Ph04) | “No, no-one has ever asked me to wait…” (Pt14) |
Diagnostic uncertainty | “It’s a hard call as to whether antibiotics are needed often with respiratory tract stuff” (GP16) | “…hard to know…we kind of explore it a bit further and suggest they need to go to the doctor for further investigation” (Ph09) | “…it’s difficult to know when it [respiratory infection] turns” (Pt13) | |
Skills: an ability or proficiency acquired through practice | ||||
Facilitators | No physical skills required to do delayed prescribing | “It’s [delayed prescribing] not difficult at all, look, it’s our job to give advice, to educate, to give our opinion. I am a GP and that’s just what I do.” (GP19) | “Look, it delayed prescribing] shouldn’t be hard – it’s coming down to talk to patients about a prescription, this is what we should be doing all the time.” (Ph11) | “No it’s [delayed prescribing] just a matter of putting a pill in your mouth and swallowing it, or not.” (Pt15) |
Interpersonal skills | “Often getting personal at this point puts it [informing patients antibiotics are not necessary] in a different perspective – I am not giving in to you because I don’t like you but if this is my child, or my grandmother, or my mother – this is what I would want to happen.” (GP02) | “I think we need to read people well, and sense where the conversation is going.” (Ph14) | “My GP has really good people skills. He doesn’t talk to me like I am stupid” (Pt10) | |
Managing expectations (asking patients) | “Of course – this is a pretty reasonable thing [asking patients what their expectations are]…having people coming in here all the time – it is difficult to know what their expectations are” (GP10) | “I ask them [patients] what we can do next, oh – what they normally do when they are sick like this.” (Ph11) | “They [GPs] do that these days – ask you what your expectations are” (Pt11) | |
Barriers | Managing expectations (not asking patients) | “No I am not a ‘what are your expectations’ doctor. But after the person brings up ‘oh, I also want this and this…’ which is the third totally separate issue, and I have already spent 15 or 20 min with them, then you do ask yourself – why didn’t I say right at the beginning ‘what are your expectations for today’?” (GP11) | “Look, there are obviously expectations, both GP expectations and patient expectations” (Ph04) | “I said to him [the GP] – you have to understand my side of the situation, I know my child…but he was not prepared to” (Pt02) |
Memory, attention and decision processes: retain information, focus selectively and choose between alternatives | ||||
Facilitators | Identifying patients | “I use it [delayed prescribing] if I think the patient trusts what I am saying and will do what I ask. So, well educated, or just the more savvy person – you can tell, they don’t need to necessarily have a degree” (GP19) | n/a | “I am in tune with myself enough to take that on [decide to commence antibiotics]. If I still felt bad on day 5, I would take the antibiotics. And I would wait if I was asked.” (Pt08) |
Barriers | Bring patients back for review | “I tell the patient if they need to, they can come back” (GP12) | n/a | “My doctor always says come back and see me…so you don’t feel like you are a bother [bulk billing practice]”. (Pt03) |
Access to medical care | “Only if…particularly say if I am working in a rural community” (GP13) | n/a | n/a | |
Travel/holiday | “It will only happen if patients are going overseas or out the country and they ask for it” (GP14) | n/a | “This could work [delayed prescribing]…if it was a long weekend or I was going travelling, that would be great” (Pt9) | |
Patients demanding antibiotics | “I can see their agenda is I need to have something, and they aren’t going to feel like they have been cared for by leaving here without anything” (GP18) | n/a | “And I said to him [the GP] but I don’t want to wait until I am really sick before I get antibiotics.” (Pt02) | |
Previous experience | “The difficulty too is you sometimes have these people come in and I say ‘oh, it looks all viral’. And then they say: ‘Well, the last time I had this I ended up in hospital with pneumonia’. So what do you do?” (GP07) | n/a | “It’s the same with my daughter – she gets sick and then I take time off work, so as a result of the doctor not giving antibiotics early, this is what ends up happening. This is what always happens.” (Pt02) | |
Pain | “…but if she has a red ear – I would offer an antibiotic. So yeah, if it shortens it by one or two days which is what the studies show – it is 1 or 2 days less of screaming." (GP04) | n/a | “…but we [GP and patient] would come to some agreement, like I am the one living with the sick child and listening to him in pain.” (Pt14) | |
Optimism: the confidence things happen for the best (includes pessimism) | ||||
Facilitators | Delayed prescribing works | “I like this approach– it [delayed prescribing] gives the patient some control in their sickness, isn’t this what we want patients to do? Surely this is a good thing, helping patients take more responsibility and educating them.” (GP19) | - | “I didn’t need it [antibiotic] in the end” (Ph10 speaking as a patient) |
Implementing an intervention could work | “I think it [a delayed prescribing intervention] would be [successful]. Especially with GPs – I think they know that patients like to have some control…as long as they [patients] understand what it is and why it [antibiotic] is not indicated at this point and when does it become, um, that puts the ball in their court.” (GP18) | “If we knew the trial was happening and we knew a prescription was part of it, we should be able to do it. With the understanding if a patient wanted it [antibiotic] after the conversation – we would still have to give it.” (Ph11) | “I actually quite like this idea [delayed prescribing] – you know – I can decide if I am sick enough to need the antibiotic.” (Pt13) | |
Barriers | Delayed prescribing will not work | “No, it [a delayed prescribing intervention] will not work. Just they are not reliable – the patients are not reliable. They will go from here and fill the script.” (GP14) | - | “Oh 95% would walk in [to a pharmacy] and get the antibiotic.” (Pt06) |
Implementing an intervention will be difficult | “I think it [a delayed prescribing intervention] would be hard without more evidence, the obvious question is how many patients go out and fill that prescription immediately.” (GP19) | “Only if…if the GP discusses it [the illness] with the patient and lets them know that they don’t have an infection yet and if it does develop in a few days and explains it correctly then it might work.” (Ph07) | “…if it’s not in their [the public’s] face or if they are not suffering or have suffered with an infection that doesn’t respond to medication then how do you make them care?” (Pt14) | |
Beliefs about consequences: acceptance of the reality about outcomes of a behaviour in a given situation | ||||
Facilitators | Continued antibiotic use will have serious consequences | “…we will have nothing to treat the basic infections with…” (GP04) | “People are taking several different antibiotics trying to get rid of infections – right down to the clarithromycin’s, and they are still not getting better” (Ph07) | “I know there is an increasing issue and there is more and more resistance to antibiotics” (Pt07) |
Delayed prescribing would reduce antibiotic use | “…less antibiotics, less resistance, less side effects.” (GP16) | “I think it’s [delayed prescribing] about them taking medicines safely, isn’t it?” (Ph13) | “It’s [delayed prescribing] going to make it better all round for antibiotic resistance…” (Pt03) | |
Delayed prescribing would reduce return visits | “It [delayed prescribing] would free up appointments.” (GP18) | - | “That would save me another trip to the doctor which I like.” (Pt09) | |
Delayed prescribing would provide an educational opportunity | “…if we take the time to educate patients here, then they learn…they will get better without antibiotics.” (GP19) | “…like really, this is a great educational moment” (Ph12) | “then maybe that message might get to people” (Pt07) | |
Delayed prescribing would support professional satisfaction | “…I just know I have done the right thing.” (GP05) | “…it [the reason to adopt delayed prescribing] is going to have to be a professional incentive, you will know you have stopped them getting an antibiotic when you thought it wasn’t needed”. (Ph10) | n/a | |
Barriers | Patients misusing prescriptions | “Some people are just going to go out and fill the prescription anyway.” (GP19) | “It would be interesting to see how many delay.” (Ph12) | “Oh 95% would walk in and get the antibiotic.” (Pt06) |
Missing a serious diagnosis | “…will I miss a pneumonia or a sepsis in the next few days?” (GP05) | n/a | “I would be worried of it [the illness] getting worse…” (Pt15) | |
Losing business | “…so losing patients” (GP05) | “We might actually lose business because we wouldn’t fill a prescription.” (Ph11) | n/a | |
Antibiotic stewardship is not my problem | “So, the enormous prescribing going on to every pregnant sheep or cow” (GP04) | “…people don’t see it [antibiotic resistance] as their problem.” (Ph07) | “I just don’t know how you could make it [antibiotic resistance] more real for people” (Pt14) | |
Taking longer | “This is a big factor [time] in general practice because if you are going to adequately explain conditions and why you are going to do what you do and do it appropriately – it takes longer.” (GP07) | “It [delayed prescribing]) can go really well if the doctors spend time with the patients” (Ph07) | “I must have come across a doctor at some stage that explained it [delayed prescribing] to me, someone who actually took the time to discuss it” (Pt03) | |
Intentions: A conscious decision to perform a behaviour or a resolve to act in a certain way | ||||
Facilitators | Intends to use delayed prescribing | “No – I just do it [delayed prescribing] really [laughing]. I don’t consciously think oh I must do that now. I just do it.” (GP16) | “Yes – it’s [talking to patients about their prescriptions] just one of the things I do. It’s part of a lot of things I just do.” (Ph10) | “And I am happy to see the doc again or if, like in your story, wait and see if it gets better or worse. I reckon I could do that.” (Pt11) |
Barriers | No intention to use delayed prescribing | “But it [delayed prescribing] doesn’t come into my mind to use.” (GP12) | n/a | n/a |
Goals: mental representations of outcomes that an individual wants to achieve | ||||
Facilitators | To use delayed prescribing | “I want to use delayed prescribing a lot if the patient can make an informed decision about their own care.” (GP19) | n/a | “If he asked me to do it [delayed prescribing] – assuming he writes out everything I need to do and when to do it, I don’t think it would be a problem, it would just be about following instructions.” (Pt15) |
To feel better | “They want to be better yesterday and tomorrow is far too long” (GP03) | “Generally I think they just want to feel better now…” (Ph06) | “And you know, if he [GP] said; ‘here, take this instead this would make you feel better’ – then I would probably take that recommendation over the antibiotics.” (Pt13) | |
Barriers | - | - | - | |
Emotions: a complex reaction by which an individual attempts to deal with a significant event | ||||
Facilitators | Reducing anxiety | “And also I think it [delayed prescribing] decreases the anxiety surrounding things like flu-like symptoms because people do feel awful, and will keep coming back but if you have explained it to them and you have given them the management plan…” (GP18) | - | “Then I would know what to do next – now I need to go to the Emergency Room, or now I need to…whatever…” (Pt12) |
Barriers | Significant event | “I couldn’t find anything wrong with the child and said it was an URTI and I won’t prescribe antibiotics because I was being really good. Of course – the child was soon having a lumbar puncture and um, having an encephalitis two minutes later, and I was: why didn’t I prescribe antibiotics? Those ones will always stay with you.” (GP04) | n/a | “But I thought he [child] had a relapse. I just didn’t know what to do – should I have done this or should I have done that…” (Pt14) |
Social influences: the interpersonal processes that can cause individuals to change their thoughts, feelings or behaviours | ||||
Facilitators | Some patients do not want antibiotics | “Some people are like ‘I don’t want to take anything, I just want to see how it goes. I want to be all natural’.” (GP09) | “Most people don’t want medication these days – they want the vitamins and the zinc! It’s such a better way to do ‘sick’, well, I think anyway.” (Ph12) | “I am so vocal that I don’t want antibiotics, so they don’t feel the need to do that with me.” (Pt03) |
Trust in patients | “Then they [the patient] learn for the rest of their lives – they will get better without antibiotics but not just that – they also learn that we have trusted them and it all worked out well.” (GP19) | - | “They [GP] are kind of going well, I am trusting, that would mean they would be trusting me as a mum, to know when my child was getting worse or better. And that I can make that judgement call myself” (Pt04) | |
Relationships with regular patients make it easier to refuse antibiotics | “Most patients that are regular that we see all the time, they are more likely to know what we will do and again if they know you reasonably well, it is easier to get them not to take things – so if they haven’t got a relationship with you, you are more likely to prescribe.” (GP04) | “…mainly because we have regular customers who believe what I say. We do have that relationship. They know I have been right before and I am not making things up or trying to sell them stuff” (Ph07) | “I wouldn’t have a problem at all [if my GP asked me to wait], I have a reasonably good relationship with my GP, I don’t always agree with what he says but… then if he asked me to wait, that would be fine with me.” (Pt14) | |
Some patients just want reassurance | “'You are doing it all ‘correctly' and then they [patients] feel reassured and maybe that has a bit of a placebo effect that they are speaking to the doctor and he has said everything is going to be OK” (GP05) | - | “just going to the doctor and him telling me I am going to be OK, if he said I didn’t need antibiotics then I would be fine with this, really, I don’t mind being told not to take tablets or to wait for that matter” (Pt13) | |
GPs don’t feel pressured by patients who demand antibiotics | “Well, I just I guess I tend to be a bit stubborn at times. If they really get up my nose, then I explain as nicely as possible all the reasons that I ah, believe it’s viral. But I will dig my heels in if they really insist” (GP11) | n/a | “Another doctor, a younger doctor – he works at the hospital but he also has rooms at the surgery, he wouldn’t give me an antibiotic. He just flatly refused.” (Pt02) | |
GPs are a trusted profession | “A position of trust I think. Being a doctor. Patients listen to you.” (GP15) | “…because not only are you getting the information from the doctor who you trust…” (Ph08) | “I do think GPs are very trusted people.” (Pt09) | |
Barriers | Expectations | “The common cold is very very common of course and people come in expecting to have antibiotics.” (GP14) | “Do you think it is because the patient goes to see the doctor expecting something?” (Ph09) | “…in my generation we were brought up to believe that antibiotics fix everything.” (Pt10) |
Lack of trust in patients | “Oh – you see – look, I don’t trust my patients enough for delayed prescribing.” (GP17) | n/a | n/a | |
Social factors | “A couple things [influence my prescribing] – what time of the week it is – like if it’s towards the end of the week – I tend to do more of the delayed prescribing – because they won’t have access to a doc over the weekend. Travel medicine. Cost is a big thing – some people are on a pension and they don’t have a lot of money, co-morbidities – smoking, diabetes, asthma – I tend to prescribe a little bit more.” (GP05) | “…well, as I said if we are busy and they [the patient] are sick or not receptive.” (Ph13) | “When she [mother] goes to the doctor for a cold, expecting antibiotics and even when I say – ‘mum these don’t work’, when she asks, he still just gives them to her. I think, for her, it’s to keep her quiet – to send her away, give her a course of antibiotics.” (Pt10) | |
Giving up control | “Some GPs have this idea that it’s better that you do it (prescribe antibiotics), and then at least you are in control of the situation” (GP07) | n/a | “If the GP said ‘Here is a prescription for antibiotics’ I would take them.” (Pt12) | |