title: Uncomfortable prescribing decisions in hospitals: the impact of teamwork.
abstract: OBJECTIVE
  Prescribing is not always driven by therapeutic motives alone; social and intrinsic factors also play a part in the decision. However, most research into prescribing influences has been conducted in general practice, with very little conducted within hospitals. One potential influence is the hospital multidisciplinary team, yet little attention has been paid to how interactions between teams and team members may influence prescribing. This study investigated the effect that team interaction and structure had upon UK hospital doctors' prescribing decisions, particularly their discomfort felt prescribing.
  
  
  METHODS
  The study used the critical incident technique and in-depth interviews. Prior to an in-depth interview, 48 doctors of varying grades from four hospitals were asked to remember any uncomfortable prescribing decisions that they had recently made. These 'incidents' were discussed in depth. All interviews were tape-recorded and transcribed verbatim. A grounded theory approach to data analysis was taken.
  
  
  RESULTS
  There were 193 critical incidents described in the interviews. Over one-third were related to the difficulties of prescribing within a team environment. Discomfort frequently arose because of factors relating to the hierarchical structure; in particular, junior doctors described their discomfort when they were uncertain of seniors' prescribing decisions. Prescribers also adhered to rules of prescribing etiquette, including the maintenance of other doctors'/teams' prescribing decisions and adherence to prescribing norms. Discomfort also arose from a perceived pressure to prescribe from the nursing team. Doctors admitted to prescribing to maintain overall team relationships, sometimes ignoring hospital regulations and best practice to do so.
  
  
  CONCLUSIONS
  Overall, this study demonstrated that hospital doctors' prescribing decisions were strongly influenced by relationships with other team members, particularly nurses and senior doctors. Ways of reducing this discomfort should be explored and further research is advocated in this area.
authors.affiliation: School of Pharmacy & Pharmaceutical Sciences, University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PT, UK. penny.lewis@manchester.ac.uk
authors.forename: Penny J
authors.initials: PJ
authors.lastname: Lewis
authors.forename: Mary P
authors.initials: MP
authors.lastname: Tully
mesh_terms: D001291:Attitude of Health Personnel; D003657:Decision Making; D011307:Drug Prescriptions; D006760:Hospitalization; D006801:Humans; D007400:Interprofessional Relations; D008505:Medical Staff, Hospital / Q000458:organization & administration / Q000523:psychology; D010348:Patient Care Team / Q000458:organization & administration*; D010818:Practice Patterns, Physicians' / Q000458:organization & administration*; D006113:United Kingdom