Table 4 Summary of qualitative papers included in the synthesis

Cortoos et al. 2008 [32]

To determine the opinions and problems concerning the use of a local antibiotic hospital guideline.

1 public tertiary care university teaching hospital

Focus Groups

7 themes reported:

Belgium

22 physicians from internal medicine (7 residents/ 6 staff) and surgery (6 residents/ 3 staff).

Framework Analysis

General attitudes and guideline interpretation;

guideline familiarity and awareness; guideline contents and agreement; social influence; multidisciplinary approach, organizational constraints; attitudes about specific interventions.

Ages: 26-60, 5 females/17 males.

Bjorkman et al. 2010 [33]

To explore and describe perceptions of antibiotic prescribing among Swedish hospital physicians.

7 acute public hospitals

Semi-structured Interviews

5 main categories of perceptions of hospital antibiotic prescribing and AMR:

Sweden

20 hospital physicians (5 urology physicians, 5 from surgery, 10 from internal medicine).

Phenomenographic Analysis

Prefer “effective” treatment; too uncertain to be restrictive; stuck in the healthcare system; aware and restrictive, but support required; aware, interested and competent.

Ages: 31-70, 5 females/15 males.

Broom et al. 2014 [34]

To investigate the experiences of doctors who prescribe antibiotics.

1 acute regional public hospital

Semi-structured Interviews

6 main themes reported:

Australia

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).

Thematic Analysis

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.

9 females/21 males.

Mattick et al. 2014 [35]

To explore the antimicrobial prescribing experiences of foundation year (FY) doctors.

2 public secondary care teaching hospitals

Narrative Interviews

6 overarching themes reported:

UK (England & Scotland)

33 junior doctors (21 FY1 and 12 FY2) working in medical and surgical wards.

Framework Analysis

Personal incident narratives about antimicrobial prescribing; antimicrobial prescribing experiences; systems issues; working relations; educational experiences and needs; process-related data.

Ages: 20-35, 18 females/15 males

May et al. 2014 [36]

To explore current practices and decision-making regarding antimicrobial prescribing among Emergency Department (ED) clinical clinicians.

8 acute hospitals, including: 5 private (2 tertiary care and 3 tertiary academic centres), 2 federal and 1 public

Semi-structured Interviews (mixed-methods study)

5 overarching themes reported:

USA

21 clinicians (attending physicians, residents, and mid-level clinicians with at least 2 years of ED experience).

Thematic Analysis

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

No gender documented.

Livorsi et al. 2015 [37]

To understand the professional and psychological factors that influence physician antibiotic prescribing habits in the inpatient setting.

2 acute teaching hospitals (1 public tertiary care and 1 federal)

Semi-structured Interviews

4 themes reported:

USA

30 inpatient physicians: 10 physicians-in-training (8 internal medicine, 2 internal medicine/paediatrics) & 20 supervisory staff (17 hospital medicine, 3 pulmonary/critical care).

Thematic Analysis

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.

10 female/20 males

Livorsi et al. 2016 [38]

To assess physician knowledge and acceptance of antibiotic-prescribing guidelines through the use of case vignettes.

2 acute teaching hospitals (1 public tertiary care and 1 federal)

Semi-structured Interviews

3 major themes reported:

USA

30 inpatient physicians: 10 physicians-in-training (8 internal medicine, 2 internal medicine/paediatrics) & 20 supervisory staff (17 hospital medicine, 3 pulmonary/critical care).

Thematic Analysis

Lack of awareness of specific guideline recommendations; tension between adhering to guidelines and the desire to individualise patient care; scepticism of certain guideline recommendations.

10 female/20 males

Skodvin et al. 2015 [39]

To investigate factors influencing antimicrobial prescribing practices among hospital doctors.

12 public and 1 private hospitals (3 teaching and 10 non-teaching)

Semi-structured Interviews

Norway

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.

Thematic Analysis

Ages: 25-65, 8 females/7 males.

Broom et al. 2016a [40]

To identify why inappropriate prescribing trends continue.

1 public teaching hospital

Semi-structured Interviews

3 major themes reported:

UK

20 doctors: 8 consultant, 12 non-consultants from medical (15) and surgical specialty (5).

Framework Analysis

Consumerism and complaints culture; priorities, team dynamics and the medical hierarchy; mythical properties of intravenous antibiotics.

9 females /11 males.

Broom et al. 2016b [41]

To explore doctors’ experiences of antibiotic prescribing, and the role of social and institutional factors in influencing the decision-making process.

1 public teaching hospital

Semi-structured Interviews

3 major themes reported:

UK

20 doctors: 8 consultant, 12 non-consultants from medical (15) and surgical specialty (5).

Framework Analysis

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.

9 females /11 males.

Broom et al. 2016c [42]

To explore the potential social dynamics underpinning doctors’ antibiotic use and infection management practices.

1 public regional teaching hospital

Semi-structured Interviews

4 main themes reported:

Australia

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.

Thematic Analysis

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.

9 females /21 males.

Eyer et al. 2016 [43]

To determine reasons for using antibiotics to treat asymptomatic bacteruria in the absence of a treatment indication.

1 public tertiary care university teaching hospital

Semi-structured Interviews

5 main themes reported:

Switzerland

21 general medicine physicians: 12 residents/9 senior physicians.

Thematic Analysis

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.

No gender documented.

Rawson et al. 2016 [44]

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.

3 public university teaching hospitals (mix of secondary and tertiary care providers)

Semi-structured Interviews

3 overarching themes reported:

UK

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).

Grounded Theory

Mapping the decision-making process; factors influencing the decision-making process; windows of influence on decision making.

No gender documented.

Broom et al. 2017 [45]

To examine how hospital doctors balance competing concerns around antibiotic use and resistance.

2 acute public teaching hospitals (1 regional and 1 metropolitan)

Semi-structured Interviews

2 key themes:

Australia

64 doctors from anaesthetics, emergency, geriatrics, gynaecology, haematology, ICU, infectious diseases, nephrology, oncology, orthopaedics, paediatrics, palliative care, respiratory, sexual health, and surgery.

Framework Analysis

The significance of resistance for the hospital and the role of doctor in perpetuating resistance; overprescribing; easier and without perceived immediate risk.

27 junior doctors, 37consultants.

28 females/36 males.

Sedrak et al. 2017 [46]

To elucidate potential barriers and enablers to the adherence to antibiotic guidelines by clinicians treating community-acquired pneumonia.

1 public tertiary teaching hospital

Semi-structured Interviews

3 main categories reported:

Australia

10 clinicians from emergency medicine (4), general medicine (4) and infectious disease (2). 5 registrars and 5 consultants.

Thematic Analysis

Knowledge, including familiarity with guidelines; attitudes, including confidence in antibiotic guidelines; behaviour, including documentation and communication, experience and clinical judgement.

5 females/5 males.