Repairing disrupted care processes as sources of stability, learning and change in a Finnish hospital: An activity-theoretical study.

INTRODUCTION: In high-income countries, it is estimated that one in every 10 patients is harmed while receiving hospital care; 50% of these are preventable. The aim of this study was to deepen our understanding of disruptions of care processes and how the repairing of disruptions can be sources of stability, learning and change in complex health care settings. METHODS: The organisational interactions associated with disruptions in the standard care processes of 15 surgical patients were followed in a public sector hospital in Finland. The patients and medical professionals were interviewed in situ during the observation of the care processes. An activity-theoretically informed methodological framework was used to identify and analyse disruptions and the associated repair efforts and repair solutions. RESULTS: Disruptions were frequent and found in all 15 care processes. These related to (1) the patient's worsening physiological state, (2) the equipment used in surgical care, (3) the information flow, (4) delays in the care process and (5) the unclear division of labour within the team. The actors carried out three types of repair efforts (technical, cognitive-emotional and extended collaborative) to overcome the disrupted processes, which usually led to repair solutions that restored stability. DISCUSSION: The different repair efforts required different kinds of collaboration and learning. Extended collaborative repair was most demanding, providing challenges and opportunities for practice change and expansive learning.

Developing a typology of interventions to support doctors' mental health and wellbeing.

BACKGROUND: The problem of mental ill-health in doctors is complex, accentuated by the COVID-19 pandemic, and impacts on healthcare provision and broader organisational performance. There are many interventions to address the problem but currently no systematic way to categorise them, which makes it hard to describe and compare interventions. As a result, implementation tends to be unfocussed and fall short of the standards developed for implementing complex healthcare interventions. This study aims to develop: 1) a conceptual typology of workplace mental health and wellbeing interventions and 2) a mapping tool to apply the typology within research and practice. METHODS: Typology development was based on iterative cycles of analysis of published and in-practice interventions, incorporation of relevant theories and frameworks, and team and stakeholder group discussions. RESULTS: The newly developed typology and mapping tool enable interventions to be conceptualised and/or mapped into different categories, for example whether they are designed to be largely preventative (by either improving the workplace or increasing personal resources) or to resolve problems after they have arisen. Interventions may be mapped across more than one category to reflect the nuance and complexity in many mental health and wellbeing interventions. Mapping of interventions indicated that most publications have not clarified their underlying assumptions about what causes outcomes or the theoretical basis for the intervention. CONCLUSION: The conceptual typology and mapping tool aims to raise the quality of future research and promote clear thinking about the nature and purpose of interventions, In doing so it aims to support future research and practice in planning interventions to improve the mental health and wellbeing of doctors.

The impact of shared social spaces on the wellness and learning of junior doctors: A scoping review.

INTRODUCTION: Impaired wellness among junior doctors is a significant problem. Connectedness and sense of belonging may be important factors to prevent and reduce mental ill-health. Shared social spaces in which health care staff can meet informally are thought to improve connectedness; however, these spaces are in decline. It is unclear what is known about such spaces, how they are used, and their impact on wellness and learning. This study aims to identify and synthetise available literature that informs our current understanding of the nature of shared social spaces as an intervention impacting wellness and learning of junior doctors. METHODS: A scoping review was conducted following the Arksey and O'Malley five-step framework. The review question is 'What is the evidence of the impact of shared social spaces on wellness and learning of junior doctors?' We searched five databases: MEDLINE, EMBASE, APA PsychINFO, APA PsychExtra, and ERIC. We conducted thorough supplementary searches in addition to the database search. RESULTS: We included 41 articles. These were predominantly letters, commentaries, and editorials with only five primary research studies. We identified four significant common attributes of shared social spaces, which can be credited with positive impacts on wellness and learning: (1) Informal: fostering connectedness and belonging, trust and teamwork and offering access to informal help and support; (2) safe: allowing reflection, debrief and raising of concerns; (3) functional: there is planning of clinical care activity, sense of control and engagement from users and provision of refreshment; (4) legitimate: regular maintenance and use of shared social spaces affect role modelling, sustainability and wellness culture. DISCUSSION: This review identified several ways in which shared social spaces impact positively on learning and wellness. There is little primary research in this area. Future research would be useful to further examine how and why this works.

Graduates' preparedness for the changing doctor-patient relationship: A qualitative study.

BACKGROUND: A positive doctor-patient relationship is a crucial part of high-quality patient care. There is a general perception that it has been changing in recent years; however, there is a lack of evidence for this. Adapting to the changing doctor-patient relationship has been identified as an important skill doctors of the future must possess. This study explores (1) multiple stakeholder perspectives on how the doctor-patient relationship is changing and (2) in what ways medical graduates are prepared for working in this changing doctor-patient relationship. METHODS: We conducted a national qualitative study involving semi-structured interviews with multiple stakeholders across the United Kingdom. Interviews lasting 45-60 minutes were conducted with 67 stakeholders including doctors in the first 2 years of practice (ECD's), patient representatives, supervisors, deans, medical educators and other health care professionals. The interviews were audiorecorded, transcribed, analysed, coded in NVivo and analysed thematically using a Thematic Framework Analysis approach. RESULTS: The main ways the doctor-patient relationship was perceived to be changing related to increased shared decision making and patients having increasing access to information. Communication, patient-centred care and fostering empowerment, were the skills identified as being crucial for preparedness to work in the changing doctor-patient relationship. Graduates were reported to be typically well-prepared for the preconditions (communication and delivering patient-centred care) of patient empowerment, but that more work is needed to achieve true patient empowerment. CONCLUSION: This study offers a conceptual advance by identifying how the doctor-patient relationship is changing particularly around the 'patient-as-knowledge-source' dimension. On the whole ECD's are well-prepared for working in the changing doctor-patient relationship with the exception of patient empowerment skills. Further research is now needed to provide an in-depth understanding of patient empowerment that is shared among key stakeholders (particularly the patient perspective) and to underpin the design of educational interventions appropriate to career stage.

A roadmap to realist interviews in health professions education research: Recommendations based on a critical analysis.

CONTEXT: Realist evaluation is increasingly employed in health professions education research (HPER) because it can unpack the extent to which complex educational interventions work (or not), for whom under what circumstances and how. While realist evaluation is not wedded to particular methods, realist interviews are commonly the primary, if not only, data collection method in realist evaluations. While qualitative interviewing from an interpretivist standpoint has been well-articulated in the HPER literature, realist interviewing differs substantially. The former elicits participants' views and experiences of a topic of inquiry, whereas realist interviewing focuses on building, testing and/or refining programme theory. Therefore, this article aims to help readers better understand, conduct, report and critique realist interviews as part of realist evaluations. METHODS: In this paper, we describe what realist approaches are, what realist interviewing is and why realist interviewing matters. We outline five stages to realist interviewing (developing initial programme theory, realist sampling/samples, the interview itself, realist analysis and reporting realist interviews), drawing on two illustrative cases from our own realist evaluations employing interviewing to bring theory to life. We provide a critical analysis of 12 realist evaluations employing interviewing in the HPER literature. Alongside reporting standards, and our own realist interviewing experiences, this critical analysis of published articles serves to foreground our recommendations for realist interviewing. CONCLUSIONS: We encourage HPE researchers to consider realist interviews as part of realist evaluations of complex interventions. Our critical analysis reveals that realist interviews can provide unique insights into HPE, but authors now need to report their sampling approach, type of interviewing and interview questions more explicitly. Studies should also more explicitly draw on existing realist interviewing literature and follow reporting guidelines for realist evaluations. We hope this paper provides a useful roadmap to conducting, reporting and critically appraising realist interviews in HPER.

Constraints and affordances for UK doctors-in-training to exercise agency: A dialogical analysis.

INTRODUCTION: The goal of medical education is to develop clinicians who have sufficient agency (capacity to act) to practise effectively in clinical workplaces and to learn from work throughout their careers. Little research has focused on experiences of organisational structures and the role of these in constraining or affording agency. The aim of this study was to identify priorities for organisational change, by identifying and analysing key moments of agency described by doctors-in-training. METHODS: This was a secondary qualitative analysis of data from a large national mixed methods research programme, which examined the work and wellbeing of UK doctors-in-training. Using a dialogical approach, we identified 56 key moments of agency within the transcripts of 22 semi-structured interviews with doctors based across the UK in their first year after graduation. By analysing action within the key moments from a sociocultural theoretical perspective, we identified tangible changes that healthcare organisations can make to afford agency. RESULTS: When talking about team working, participants gave specific descriptions of agency (or lack thereof) and used adversarial metaphors, but when talking about the wider healthcare system, their dialogue was disengaged and they appeared resigned to having no agency to shape the agenda. Organisational changes that could afford greater agency to doctors-in-training were improving induction, smoothing peaks and troughs of responsibility and providing a means of timely feedback on patient care. CONCLUSIONS: Our findings identified some organisational changes needed for doctors-in-training to practise effectively and learn from work. The findings also highlight a need to improve workplace-based team dynamics and empower trainees to influence policy. By targeting change, healthcare organisations can better support doctors-in-training, which will ultimately benefit patients.

'The WOW factors': comparing workforce organization and well-being for doctors, nurses, midwives and paramedics in England.

BACKGROUND: High rates of poor mental health in healthcare staff threatens the quality and sustainability of healthcare delivery. Multi-factorial causes include the nature and structure of work. We conducted a critical review of UK NHS (England) data pertaining to: doctors, nurses, midwives and paramedics. SOURCES OF DATA: Key demographic, service architecture (structural features of work) and well-being indicators were identified and reviewed by a stakeholder group. Data searching prioritized NHS whole workforce sources (focusing on hospital and community health services staff), which were rated according to strength of evidence. FINDINGS: Key differences between professions were: (i) demographics: gender (nursing and midwifery female-dominated, doctors and paramedics more balanced); age (professions other than doctors had ageing workforces); ethnicity (greater diversity among doctors and nurses); (ii) service architecture: despite net staffing growth, turnover and retention were problematic in all professions; 41.5% doctors were consultants but smaller proportions held high grade/band roles in other professions; salaries were higher for doctors; (iii) well-being: all reported high job stress, particularly midwives and paramedics; sickness absence rates for nurses, midwives and paramedics were three times those of doctors, and presenteeism nearly double. GROWING POINTS: Sociocultural factors known to increase risk of poor mental health may explain some of the differences reported between professions. These factors and differences in service architecture are vital considerations when designing strategies to improve well-being. AREAS TIMELY FOR DEVELOPING RESEARCH: Multi-level systems approaches to well-being are required that consider intersectionality and structural differences between professions; together with inter-professional national databases to facilitate monitoring.

Typologies of education and training pathways for general practitioners: a scoping review.

Introduction: Variation in medical education and training amongst countries is well reported but evidence syntheses of similarities and differences are rare. We developed a typology of education and training pathways for General Practitioners (or equivalent) based on a scoping review of international peer-reviewed literature.Methods: Applying search terms such as 'General practice' or 'Family medicine' and 'medical education or training' in Ovid Medline, Embase, and ERIC, identified studies published since 2010 describing education and training pathways for GPs. Inclusion criteria were used to select studies for data extraction and thematic analysis to characterise distinct typologies.Results: 90 articles were included in the scoping review of which 47 discussed both undergraduate and postgraduate programmes and three typologies based on GPs' role in the healthcare system identified:'Gatekeeper': Patients cannot access secondary or tertiary service without GP referral.'Doctor of choice': Patients can choose to see a specialist and access secondary or tertiary care directly.'Team member': Patients can access a network of health professionals in the community.Conclusion: The typology provides a reference for medical educators and policymakers. Conceptualising the diversity in education and training pathways can inform the implementation of educational and training transformation for GPs in different contexts.

Optimising strategies to address mental ill-health in doctors and medical students: 'Care Under Pressure' realist review and implementation guidance.

BACKGROUND: Mental ill-health in health professionals, including doctors, is a global and growing concern. The existing literature on interventions that offer support, advice and/or treatment to sick doctors has not yet been synthesised in a way that considers the complexity and heterogeneity of the interventions, and the many dimensions of the problem. We (1) reviewed interventions to tackle doctors' and medical students' mental ill-health and its impacts on the clinical workforce and patient care-drawing on diverse literature sources and engaging iteratively with diverse stakeholder perspectives-and (2) produced recommendations that support the tailoring, implementation, monitoring and evaluation of contextually sensitive strategies to tackle mental ill-health and its impacts. METHODS: Realist literature review consistent with the RAMESES quality and reporting standards. Sources for inclusion were identified through bibliographic database searches supplemented by purposive searches-resulting also from engagement with stakeholders. Data were extracted from included articles and subjected to realist analysis to identify (i) mechanisms causing mental ill-health in doctors and medical students and relevant contexts or circumstances when these mechanisms were likely to be 'triggered' and (ii) 'guiding principles' and features underpinning the interventions and recommendations discussed mostly in policy document, reviews and commentaries. RESULTS: One hundred seventy-nine records were included. Most were from the USA (45%) and were published since 2009 (74%). The analysis showed that doctors were more likely to experience mental ill-health when they felt isolated or unable to do their job and when they feared repercussions of help-seeking. Healthy staff were necessary for excellent patient care. Interventions emphasising relationships and belonging were more likely to promote wellbeing. Interventions creating a people-focussed working culture, balancing positive/negative performance and acknowledging positive/negative aspects of a medical career helped doctors to thrive. The way that interventions were implemented seemed critically important. Doctors and medical students needed to have confidence in an intervention for the intervention to be effective. CONCLUSIONS: Successful interventions to tackle doctors' and students' mental ill-health are likely to be multidimensional and multilevel and involve multiple stakeholders. Evaluating and improving existing interventions is likely to be more effective than developing new ones. Our evidence synthesis provides a basis on which to do this. STUDY REGISTRATION: PROSPERO CRD42017069870. Research project webpage http://sites.exeter.ac.uk/cup/.

Tolerance of ambiguity and psychological well-being in medical training: A systematic review.

CONTEXT: The prevalence of stress, burnout and mental health disorders in medical students and doctors is high. It has been proposed that there may be an association between levels of tolerance of ambiguity (ie an ability to tolerate a lack of reliable, credible or adequate information) in clinical work and psychological well-being within this population. The aims of this systematic review were: (i) to assess the nature and extent of the literature available, in order to determine if there is an association, and (ii) to develop a conceptual model proposing possible mechanisms to underpin any association, in order to inform subsequent research. METHODS: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO databases were searched for articles published from inception to September 2018. Additional literature was identified by searching the reference lists of included articles, forward searches of included articles, hand searches of key journals and a grey literature search. Of the 671 studies identified, 11 met the inclusion criteria. A qualitative synthesis of included studies was performed. RESULTS: All 11 included studies reported an association between a lower level of tolerance of ambiguity or uncertainty and reduced psychological well-being. Included studies were heterogeneous in terms of population and measurement approach, and were often of low methodological quality. Subsets of items from previously developed scales were often used without sufficient consideration of the impact of new combinations of items on scale validity. Similar scales were also scored inconsistently between studies, making comparison difficult. CONCLUSIONS: There appears to be an association between tolerance of ambiguity and psychological well-being. This provides new opportunities to understand and prevent the development of stress, burnout and mental health disorders in medical students and doctors. The conceptual model developed provides a framework for future research, which we hope will prevent wasted research effort through duplication and promote higher methodological quality.

The case for faculty development: A realist evaluation.

CONTEXT: It seems logical to suggest that investing in educators will lead to improved educational outcomes. However, in the case of faculty development, it is unclear how these benefits arise and decisions about investment typically have little basis in evidence. The aim of this realist evaluation was to understand the mechanisms by which investment in faculty development may lead to improved educational outcomes for staff and students. METHODS: This realist evaluation involved three phases: the development of an initial programme theory based on existing peer-reviewed literature (Phase 1), which was used within 32 realist interviews with key stakeholders at 17 UK medical schools (Phase 2), to underpin the creation of a series of recommendations for faculty development programme designers (Phase 3). RESULTS: The findings highlighted the complex and heterogeneous nature of faculty development programmes. Programme developers must consider a range of contexts (accreditation, meeting educational needs, learning culture, accessibility and interactivity) that can impact faculty members in variable ways (engagement, sense of value and belonging, motivation, reassurance and building relationships), potentially resulting in a range of staff outcomes (improved competence, satisfaction, confidence, faculty member collaboration and curriculum changes) that may ultimately benefit students. The improved understanding resulting from Phases 1 and 2, and the recommendations from Phase 3, will enable the design and tailoring of new and existing faculty development initiatives. CONCLUSIONS: This study deepens our understanding of the role of context in faculty development through the realist methodology employed and extends pre-existing knowledge to provide insights into evidence-based interventional strategies that may be effective. In particular, faculty development leads need to develop a clear implementation strategy, improve transparency of cashflow, establish effective formal or informal communication systems and evaluate the efficacy of their faculty development initiatives.

Pharmacist-led, video-stimulated feedback to reduce prescribing errors in doctors-in-training: A mixed methods evaluation.

AIMS: To develop and evaluate a feasible, authentic pharmacist-led prescribing feedback intervention for doctors-in-training, to reduce prescribing errors. METHODS: This was a mixed methods study. Sixteen postgraduate doctors-in training, rotating though the surgical assessment unit of 1 UK hospital, were filmed taking a medication history with a patient and prescribing medications. Each doctor reviewed their video footage and made plans to improve their prescribing, supported by feedback from a pharmacist. Quantitative data in the form of prescribing error prevalence data were collected on 1 day per week before, during and after the intervention period (between November 2015 and March 2017). Qualitative data in the form of individual semi-structured interviews were collected with a subset of participants, to evaluate their experience. Quantitative data were analysed using a statistical process chart and qualitative data were transcribed and analysed thematically. RESULTS: During the data collection period, 923 patient drug charts were reviewed by pharmacists who identified 1219 prescribing errors overall. Implementation of this feedback approach was associated with a statistically significant reduction in the mean number of prescribing errors, from 19.0/d to 11.7/d (estimated to equate to 38% reduction; P < .0001). Pharmacist-led video-stimulated prescribing feedback was feasible and positively received by participants, who appreciated the reinforcement of good practice as well as the opportunity to reflect on and improve practice. CONCLUSIONS: Feedback to doctors-in-training tends to be infrequent and often negative, but this feasible feedback strategy significantly reduced prescribing errors and was well received by the target audience as a supportive developmental approach.

Optimising feedback for early career professionals: a scoping review and new framework.

CONTEXT: Meta-analyses have shown that feedback can be a powerful intervention to increase learning and performance but there is significant variability in impact. New trials are adding little to the question of whether feedback interventions are effective, so the focus now is how to optimise the effect. Early career professionals (ECPs) in busy work environments are a particularly important target group. This literature review aimed to synthesise information to support the optimal design of feedback interventions for ECPs. METHODS: We undertook a scoping literature review, using search terms such as 'feedback' and 'effectiveness' in MEDLINE, MEDLINE-In-Process, PsycINFO, CINAHL, Education Research Complete, Education Resources Information Center, the Cochrane Database of Systematic Reviews, the Social Sciences Citation Index and Applied Social Sciences Index and Abstracts, to identify empirical studies describing feedback interventions in busy workplaces published in English since 1990. We applied inclusion criteria to identify studies for the mapping stage and extracted key data to inform the next stage. We then selected a subset of papers for the framework development stage, which were subjected to a thematic synthesis by three authors, leading to a new feedback framework and a modified version of feedback intervention theory specifically for ECPs. RESULTS: A total of 80 studies were included in the mapping stage, with roughly equal studies from hospital settings and school classrooms, and 17 papers were included in the framework development stage. The feedback framework comprised three main categories (audit, feedback and goal setting) and 22 subcategories. The review highlighted the limited empirical research focusing solely on feedback for ECPs, which was surprising given the particular nuances in feedback for ECPs identified through this study. CONCLUSIONS: We offer the feedback framework to optimise the design of future feedback interventions for early career professionals and encourage future feedback research to move away from generic models and tailor work to specific target audiences.

"I'd been like freaking out the whole night": exploring emotion regulation based on junior doctors' narratives.

The importance of emotions within medical practice is well documented. Research suggests that how clinicians deal with negative emotions can affect clinical decision-making, health service delivery, clinician well-being, attentiveness to patient care and patient satisfaction. Previous research has identified the transition from student to junior doctor (intern) as a particularly challenging time. While many studies have highlighted the presence of emotions during this transition, how junior doctors manage emotions has rarely been considered. We conducted a secondary analysis of narrative data in which 34 junior doctors, within a few months of transitioning into practice, talked about situations for which they felt prepared or unprepared for practice (preparedness narratives) through audio diaries and interviews. We examined these data deductively (using Gross' theory of emotion regulation: ER) and inductively to answer the following research questions: (RQ1) what ER strategies do junior doctors describe in their preparedness narratives? and (RQ2) at what point in the clinical situation are these strategies narrated? We identified 406 personal incident narratives: 243 (60%) contained negative emotion, with 86 (21%) also containing ER. Overall, we identified 137 ER strategies, occurring prior to (n = 29, 21%), during (n = 74, 54%) and after (n = 34, 25%) the situation. Although Gross' theory captured many of the ER strategies used by junior doctors, we identify further ways in which this model can be adapted to fully capture the range of ER strategies participants employed. Further, from our analysis, we believe that raising medical students' awareness of how they can handle stressful situations might help smooth the transition to becoming a doctor and be important for later practice.

Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review.

Background: Antimicrobial resistance has led to widespread implementation of interventions for appropriate prescribing. However, such interventions are often adopted without an adequate understanding of the challenges facing doctors-in-training as key prescribers. Methods: The review followed a realist, theory-driven approach to synthesizing qualitative, quantitative and mixed-methods literature. Consistent with realist review quality standards, articles retrieved from electronic databases were systematically screened and analysed to elicit explanations of antimicrobial prescribing behaviours. These explanations were consolidated into a programme theory drawing on social science and learning theory, and shaped though input from patients and practitioners. Results: By synthesizing data from 131 articles, the review highlights the complex social and professional dynamics underlying antimicrobial prescribing decisions of doctors-in-training. The analysis shows how doctors-in-training often operate within challenging contexts (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels, uncertainty about application of knowledge in practice) where they prioritize particular responses (fear of criticism and individual responsibility, managing one's reputation and position in the team, appearing competent). These complex dynamics explain how and why doctors-in-training decide to: (i) follow senior clinicians' prescribing habits; (ii) take (or not) into account prescribing aids, advice from other health professionals or patient expectations; and (iii) ask questions or challenge decisions. This increased understanding allows for targeted tailoring, design and implementation of antimicrobial prescribing interventions. Conclusions: This review contributes to a better understanding of how antimicrobial prescribing interventions for doctors-in-training can be embedded more successfully in the hierarchical and inter-professional dynamics of different healthcare settings.

Comparing Tolerance of Ambiguity in Veterinary and Medical Students.

Current guidelines suggest that educators in both medical and veterinary professions should do more to ensure that students can tolerate ambiguity. Designing curricula to achieve this requires the ability to measure and understand differences in ambiguity tolerance among and within professional groups. Although scales have been developed to measure tolerance of ambiguity in both medical and veterinary professions, no comparative studies have been reported. We compared the tolerance of ambiguity of medical and veterinary students, hypothesizing that veterinary students would have higher tolerance of ambiguity, given the greater patient diversity and less well-established evidence base underpinning practice. We conducted a secondary analysis of questionnaire data from first- to fourth-year medical and veterinary students. Tolerance of ambiguity scores were calculated and compared using the TAMSAD scale (29 items validated for the medical student population), the TAVS scale (27 items validated for the veterinary student population), and a scale comprising the 22 items common to both scales. Using the TAMSAD and TAVS scales, medical students had a significantly higher mean tolerance of ambiguity score than veterinary students (56.1 vs. 54.1, p<.001 and 60.4 vs. 58.5, p=.002, respectively) but no difference was seen when only the 22 shared items were compared (56.1 vs. 57.2, p=.513). The results do not support our hypothesis and highlight that different findings can result when different tools are used. Medical students may have slightly higher tolerance of ambiguity than veterinary students, although this depends on the scale used.

The determinants of antimicrobial prescribing among hospital doctors in England: a framework to inform tailored stewardship interventions.

AIM: Little is known about the determinants of antimicrobial prescribing behaviour (APB), how they vary between hospital prescribers or the mechanism by which interventions are effective. Yet, interventions based on a sound theoretical understanding of APB are more likely to be successful in changing outcomes. This study sought to quantify the potential determinants of APB among hospital doctors in south-west England. METHODS: This multicentre, quantitative study employed a closed answer questionnaire to garner hospital doctors' views on factors influencing their APB. Underlying constructs within the data were identified using exploratory factor analysis and subsequent pairwise comparisons assessed for variance between groups of prescribers. RESULTS: The questionnaire was completed by 301 doctors across four centres (response rate ≥ 74%) and three key factors were identified: autonomy, guidelines adherence and antibiotic awareness. The internal consistency for the questionnaire scale and for each factor subscale was good (α ≥ 0.7). Subgroup analysis identified significant differences between groups of prescribers: autonomy scores increased with grade until at the specialist trainee level (P ≤ 0.009), foundation doctors scored higher for guidelines adherence than consultants (P = 0.004) and specialist trainees (P = 0.003) and United Kingdom trained doctors scored higher than those trained abroad for antibiotic awareness (P < 0.0005). Scores did not vary significantly between doctors from different centres. CONCLUSION: Autonomy, guidelines adherence and antibiotic awareness were identified as important factors relevant to APB, which vary with experience and training. A theoretical framework is offered to facilitate development of more effective, tailored interventions to change APBs.