Trainee doctors' experiences of common problems in the antibiotic prescribing process: an activity theory analysis of narrative data from UK hospitals

BMJ Open. 2019 Jun 11;9(6):e028733. doi: 10.1136/bmjopen-2018-028733.


Introduction: Prescribing antibiotics is an error-prone activity and one of the more challenging responsibilities for doctors in training. The nature and extent of challenges experienced by them at different stages of the antibiotic prescribing process are not well described, meaning that interventions may not target the most problematic areas.

Objectives: Our aim was to explore doctors in training experiences of common problems in the antibiotic prescribing process using cultural-historical activity theory (CHAT). Our research questions were as follows: What are the intended stages in the antibiotic prescribing process? What are the challenges and where in the prescribing process do these occur?

Methods: We developed a process model based on how antibiotic prescribing is intended to occur in a 'typical' National Health Service hospital in the UK. The model was first informed by literature and refined through consultation with practising healthcare professionals and medical educators. Then, drawing on CHAT, we analysed 33 doctors in training narratives of their antibiotic prescribing experiences to identify and interpret common problems in the process.

Results: Our analysis revealed five main disturbances commonly occurring during the antibiotic prescribing process: consultation challenges, lack of continuity, process variation, challenges in patient handover and partial loss of object. Our process model, with 31 stages and multiple practitioners, captures the complexity, inconsistency and unpredictability of the process. The model also highlights 'hot spots' in the process, which are the stages that doctors in training are most likely to have difficulty navigating.

Conclusions: Our study widens the understanding of doctors in training prescribing experiences and development needs regarding the prescribing process. Our process model, identifying the common disturbances and hot spots in the process, can facilitate the development of antibiotic prescribing activities and the optimal design of interventions to support doctors in training.

Keywords: antibiotic prescribing; cultural historical activity theory; disturbance; process; trainee doctor.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Analysis of Variance
  • Anti-Bacterial Agents / therapeutic use*
  • Continuity of Patient Care
  • Drug Prescriptions* / standards
  • Drug Prescriptions* / statistics & numerical data
  • Hospitals / statistics & numerical data
  • Humans
  • Medical Staff, Hospital* / education
  • Medical Staff, Hospital* / psychology
  • Patient Handoff
  • Practice Patterns, Physicians'*
  • State Medicine
  • United Kingdom


  • Anti-Bacterial Agents