UNCOMFORTABLE PRESCRIBING
DECISIONS IN SECONDARY CARE
Background
It is generally accepted that prescribing is not necessarily driven by purely
therapeutic motives and that various influencing social and intrinsic factors
play a part in the decision to prescribe.1 However, the majority of
research into prescribing influences has focused on the primary care setting,
with very little research conducted in secondary care. To learn more about
influences on prescribing in secondary care, a small-scale pilot study was
undertaken, using a technique that has been used to good effect in the primary
care sector.2
Method
A letter of invitation to take part in the pilot study, along with a short
self-completion questionnaire, was sent to 139 doctors working within one
teaching hospital. Eight doctors were purposively selected for interview,
covering each grade so as to replicate a firm. Participants were selected to
provide two groups of doctors: one from medicine and one from surgery. Letters
were sent to participants prior to interview requesting them to remember any
instances where they felt uncomfortable when making a prescribing decision,
regardless of whether a prescription was issued. By focusing on ‘uncomfortable
decisions’, using a technique known as the ‘critical incident technique’ (CIT),
it is possible to avoid general perceptions about what doctors believe
influences their prescribing. Complex decision-making processes are often
difficult to explore and explain but, with the CIT, what is often an unconscious
process can be unpacked by asking doctors to recall real-life examples when
prescribing was problematic in some way. During the interview, the incident(s)
were discussed in-depth, and more general themes emerging from the literature
and the interviews themselves were also explored. All interviews were
tape-recorded and transcribed verbatim. Data analysis was approached with a
modified grounded theory technique.
Findings
All eight participants were able to recall at least one incident of
uncomfortable prescribing, with most discussing several incidents. The types of
medications associated with discomfort varied. However, discomfort when
prescribing opiates was a common theme. The preliminary findings suggest that
causes of uncomfortable prescribing decisions relate to issues such as a fear of
producing side effects, a fear of litigation and unfamiliarity with the
medication or medical condition. The exact nature of these issues appears to
vary with the doctors’ seniority. Doctors also discussed their discomfort when
prescribing on the request of another doctor or nurse; participants believed
that this derived from a lack of knowledge of the patient, further exacerbated
whilst on-call. Furthermore, the extent that a doctor trusted his or her
colleagues played an important role in the manifestation of this
discomfort.
Discussion
This pilot study suggests that there are some important influences that can
provoke discomfort in a secondary care prescriber; many of these findings are
inline with previous studies in primary care.2 However, the study
revealed some previously unreported sources of discomfort, perhaps more
pertinent to the secondary care setting. Information about prescribing
influences is valuable to those who wish to influence and improve prescribing;
further study of uncomfortable prescribing decisions in secondary care will
provide a deeper knowledge of these influences.
References
-
Freeman AC, Sweeney K. Why general practitioners do not
implement evidence: qualitative study. BMJ 2001; 323(7321):1100-1102.
-
Bradley CP. Uncomfortable prescribing decisions: a
critical incident study. BMJ 1992; 304(6822):294-296.
Presented at the HSRPP Conference 2005, Reading
|
