Table 6 Opportunity themes and key quotes

Everyone is responsible for appropriate prescribing and decision making

“I think all of the medical professionals involved in the patient’s care should be responsible [for appropriate antimicrobial prescribing]. … Everybody. The pharmacist, the surgeons, the ID physicians, the general physicians, the microbiologists, the whole lot and the hospital executive are responsible as well. … Everybody looking after patients need to know when to use antibiotics and which ones to use, for how long, and doses, everybody needs to know that.” (CM 1, FG 1)

“And because I don’t admit patients myself, so although I’m responsible for in part of their care … I’m not the decision maker on which antibiotic and unfortunately I sometimes have to give what I don’t necessarily think what is necessary or correct.” (Anaesthetist, FG 2)

Specialist staff supporting AMS are valued by clinicians

“Executive 2: we have an antimicrobial stewardship pharmacist… He works closely with the infectious diseases doctors and he tracks and monitors that and reports in a sort of governance way every month …

Pharmacist: … the AMS pharmacist does a brilliant job and does have a huge role in intervening, monitoring, and then obviously reporting back” (FG 3)

“We’re blessed with very good ID physician cover here, so that no matter what happens you usually get someone involved if you need to for specialist areas.” (Endocrinologist, FG 2)

“Nursing staff are really valuable … they’re our allies… they’re a very vital key in that chain because they’re the ones who are on the wards… all the nursing staff see all the patients, so they can highlight something that’s going on.” (CM1, FG1)

“Within our departments [nursing staff are] probably the best person on the ward that knows everything that’s going on. So, we can contribute.” (NUM2, FG 3)

Clinicians value their autonomy

“No idea what the [hospital] guidelines are. But I’m not changing mine [prescribing practices]. I’m like that surgeon of yours. I haven’t had an infection in 19 years, mine are working.” (Cardiologist, FG 2)

“I guess because we’re used to seeing it and the certain people who have a certain preference or a certain way of doing things, whether or not it matches guidelines or not, we sometimes forget to question it.” (Pharmacist, FG 3)

“one of the surgeons has his own variation on [the surgical prophylaxis guidelines]. And I’m not the decision-maker for which antibiotic. So, if he wants that, as long as the patient’s not allergic to it or there is no other contraindication, so, a joint replacements, I know cephazolin is the drug we should be using but he adds ceftriaxone” (Anaesthetist, FG 2)

“NUM3: A lot of [the doctors], they don’t read [the guidelines]. Even if they do, like we said, they’ve just got their practice. Because it is a culture, no one’s forcing them to do anything. They don’t actually have any rules

NUM2: Yeah, they can do what they want. Basically.” (FG3)

“Pharmacist: if the prescriber says that “well I’ve done that for 5 years and I’ve never had an infection so why wouldn’t I?” … It’s hard to argue that resistance thing ‘cause they know for them their patients have had a good outcome

NUM 2: And it could be related to the antibiotic or it could just be related to their practice

Pharmacist: Yeah, the antibiotic might not be necessary.” (FG3)

Leadership is needed for AMS success

“You feel like it needs to come from you know, the medical director … we can question as much as we like but I don’t think … it will particularly change their practice.” (NUM 3, FG 3)

“If the ICU consultant can’t event ask the surgeon a question, how can the nurses ask them a question?” (NUM 4, FG 3)

“It’s kind of like, who governs the prescribing doctors here? … is it the exec or is like the medical director? And if you raise it what kind of response are you going to get? … but there’s not that much governance in the private sector, in my experience. I worked in the public system a really long time ago, but here they can just do what they want.” (NUM 2, FG 3)

“I think that’s where sometimes when we talk about being a private organisation, that has lots of visiting doctors… you can’t give them rules but you can give them guides. Where sort of the passive audit approach is potentially helpful to say well, this is the guide and this is what you’re doing – can we talk about it? And that’s about as far as our senior people can actually… question those prescribers that you can’t question… They’re never going to change unless it happens from above, there’s no point the nurses calling or myself calling for that.” (Pharmacist, FG 3)

“[The AMS program] has the support of the hospital and the executive because without that it would never be successful, and I think it is very successful here” (Clinical Microbiologist 1, FG 1)