499 Exploring intern doctors’ views and experiences of prescribing at hospital discharge: a qualitative interview study
Authors: Nicolaou-Ghekas B , Byrne A , Dalton K 
Published: April 2023

Introduction

Prescribing errors at hospital discharge remain to be highly prevalent; therefore, there is a clear need to identify novel strategies to address this and minimise patient harm. Even though prescribing at discharge is commonly tasked to junior doctors, there is a paucity of qualitative research that has focused on investigating this group's perspectives on prescribing at this critical healthcare interface.

Aim

To explore the views and experiences of intern doctors (i.e. those with ≤12 months’ post-qualification hospital-based experience) regarding prescribing at hospital discharge.

Methods

Using a topic guide based on the Theoretical Domains Framework (TDF), semi-structured face-to-face interviews were conducted with intern doctors in an acute teaching hospital between June and July 2022 (1). It was decided a priori to initially interview a purposive sample of eight interns (four medical and four surgical at the time of the interview). Thereafter, once two consecutive additional interviews did not identify any new major themes, this confirmed that the topic had been adequately explored and that no further sampling was needed (2). Recruitment was via convenience sampling and snowballing. Content analysis (CA) of the interview transcripts was performed to identify the relevant TDF domains that influenced intern doctors’ discharge prescribing (via directed CA) and the conventional themes to be described under each domain (via conventional CA).

Results

Ten intern doctors were interviewed (five medical, five surgical), each with 11-12 months of post-qualification hospital-based experience. The mean interview length was 25 minutes. Five TDF domains were identified as predominant in influencing intern doctors’ discharge prescribing:

i)‘Environmental Context and Resources’: the busy hospital environment, with an intense workload and external pressures to discharge patients quicker, negatively impacted this prescribing.

ii)‘Social Influences’: support primarily came from senior doctor colleagues and pharmacists; however, interns felt more isolated with this process on surgical teams. Interns described the influence of hospital hierarchy, where at times they followed their senior colleagues’ prescribing directions even if it conflicted with evidence-based guidelines.

iii)‘Knowledge’: interns perceived that medical school did not prepare them sufficiently for discharge prescribing, and feared appearing incompetent if they asked too many questions.

iv)‘Memory, Attention and Decision Processes’: interns noted the need to sometimes be assertive with other healthcare professionals not to be distracted, as they needed to focus their attention whilst discharge prescribing.

v)‘Behavioural Regulation’: some interns took great pride in being precise when discharge prescribing to avoid receiving calls from pharmacies – an incentive to minimise errors and additional work. Interviewees emphasised the lack of structured, formal feedback and the need for increased monitoring of their discharge prescriptions to promote self-reflection.

Conclusion

This study has provided a deeper understanding of the behavioural influences on intern doctors' discharge prescribing, the challenges they face, and suggested possible mechanisms to better support junior doctors. Whilst this research is limited by its single-centred nature, the employment of the TDF has allowed the identification of domains that could be targeted when developing theoretically-informed strategies to positively impact on junior doctors’ prescribing behaviours and ultimately minimise patient harm.

References

1. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012; 7: 37

2. Francis JJ, Johnston M, Robertson C, Glidewell L, Entwistle V, Eccles MP, Grimshaw JM. What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychology and health. 2010 Dec 1;25(10):1229-45.