The path of least resistance? Jurisdictions, responsibility and professional asymmetries in pharmacists' accounts of antibiotic decisions in hospitals

Social Science & Medicine 146 (2015) 95e103

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Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed

The path of least resistance? Jurisdictions, responsibility and professional asymmetries in pharmacists' accounts of antibiotic decisions in hospitals Alex Broom a, *, Jennifer Broom b, Emma Kirby a, Graham Scambler c a b c

School of Social Sciences, The University of New South Wales, Sydney, Australia Department of Medicine, Sunshine Coast Hospital and Health Service, Australia Department of Sociology, University of Surrey, Guildford, United Kingdom

a r t i c l e i n f o

a b s t r a c t

Article history: Received 28 December 2014 Received in revised form 16 October 2015 Accepted 16 October 2015 Available online 19 October 2015

The misuse of antibiotics has become a major public health problem given the global threat of multiresistant organisms and an anticipated ‘antimicrobial perfect storm’ within the next few decades. Despite recent attempts by health service providers to optimise antibiotic usage, widespread inappropriate use of antibiotics continues in hospitals internationally. In this study, drawing on qualitative interviews with Australian pharmacists, we explore how they engage in antibiotic decisions in the hospital environment. We develop a sociological understanding of pharmacy as situated within evolving interprofessional power relations, inflected by an emerging milieu whereby antibiotic optimisation is organisationally desired but interprofessionally constrained. We argue that the case of antibiotics articulates important interprofessional asymmetries, positioning pharmacists as delimited negotiators within the context of medical prescribing power. We conclude that jurisdictional uncertainties, and the resultant interprofessional dynamics between pharmacy and medicine, are vital delimiting factors in the emerging role of pharmacists as ‘antimicrobial stewards’ in the hospital environment. Moreover, we argue that a nuanced understanding of the character of interprofessional negotiations is key to improving the use of antibiotics within and beyond the hospital. © 2015 Elsevier Ltd. All rights reserved.

Keywords: Australia Sociology Qualitative Pharmacy Hospital Antibiotics

1. Introduction The pharmacy profession has traditionally received less attention from sociologists than other healthcare professions with only sporadic attention over the last few decades (e.g. Denzin and Mettlin, 1968; Eaton and Webb, 1979; Mesler, 1991). In the context of an historic but persistent medical dominance in the health sector, there has been a focus within sociology on professional identity work, professionalisation and role delineations within nursing, physiotherapy, midwifery and social work (ApesoaVarano, 2013; see Denzin and Mettlin, 1968; Svensson, 1996). This has meant that the social context and interprofessional dynamics associated with pharmacy, and its relations across the health sector, have been less transparent (Chiarello, 2013; Weiss and Sutton,

* Corresponding author. E-mail addresses: [email protected] (A. Broom), [email protected]. gov.au (J. Broom), [email protected] (E. Kirby), [email protected] (G. Scambler). http://dx.doi.org/10.1016/j.socscimed.2015.10.037 0277-9536/© 2015 Elsevier Ltd. All rights reserved.

2009). Yet, pharmacy occupies an increasingly influential position within the rationalisation of healthcare delivery (Weiss and Sutton, 2009), playing key roles in practices of (enhanced) systematisation, computerisation and decision-making around medications in particular (Weiss and Sutton, 2009; Chiarello, 2013). Moreover, the broader expansion of biomedicine in the latter half of the 20th Century was accompanied by an expansion in the pharmacy role, including being directly involved at the bedside (e.g. Rosenthal et al., 2014). Thus, in hospital settings, pharmacists are prominent actors in the dynamics of team-based care, albeit operating within a particular distinct professional order involving potential power imbalances (Weiss and Sutton, 2009). In the context of antibiotic use in the hospital and the rise of antimicrobial stewardship (AMS) programs internationally (CDC, 2014; IDSA, 2014), pharmacy has become an important player in attempts to moderate antibiotic use (e.g. Cairns et al., 2013; Hand, 2007; Ingram et al., 2012). Antimicrobial stewardship refers to: coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the

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optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration (IDSA, 2014). This drive to optimise antibiotics through AMS programs reflects recognition of an anticipated antimicrobial perfect storm within the next few decades, driven by rapidly diminishing antibiotic drug development, antibiotic overuse and the proliferation of multi-resistant organisms. Given the paucity of antibiotic options in development, there is broad agreement that an immediate tightening of antibiotic use internationally is urgently needed (CDC, 2014; IDSA, 2014), including, but not restricted to, the hospital sector (Fridkin and Srinivasan, 2013). Yet, AMS programs have had limited effects over time in Australia and internationally (Cairns et al., 2013), with, for example, between 20 and 50% of antibiotics utilised in Australian hospitals deemed clinically inappropriate (ACSQHC, 2014; Ingram et al., 2012). Similar results have been shown in studies of hospital-based antibiotic use in Europe and North America (e.g. Zarb and Goossens, 2011). While an understanding of the day-today pressures on hospital-based doctors and the various social dynamics underpinning antibiotic misuse is beginning to emerge (e.g. Broom et al., 2014, 2015), there is little research exploring pharmacy perspectives (Roque et al., 2014, 2015). The aforementioned shift in priorities in health policy toward more judicious and appropriate antibiotic use globally presents significant implications for interprofessional relations between medicine and pharmacy (Weiss and Sutton, 2009). The rise of AMS, and the importance of pharmacists within such initiatives (CDC, 2014; IDSA, 2014), offers up the potential for important shifts in interprofessional dynamics (e.g. Hand, 2007). Thus, drawing on the accounts of hospital pharmacists, in this sociological analysis we argue that the arena of antibiotic use within hospitals reveals persistent but evolving professional asymmetries between pharmacy and medicine. Moreover, that understanding these dynamics is critical for the development of global strategies to optimise antibiotic use in hospital contexts. 2. Background 2.1. Pharmacy in interprofessional context It is useful to briefly reflect on the historical position, role and evolution of pharmacy. The role of pharmacy has continued to evolve over the latter half of the 20th Century, including moves to delineate and enhance pharmacy's role and responsibilities in healthcare delivery (Denzin and Mettlin, 1968; Eaton and Webb, 1979; Mesler, 1991). As Denzin and Mettlin (1968) outlined several decades ago, pharmacy initially received limited recognition in terms of professional role and power, suffering from a perception of merely delivering and counting drugs on the orders of physicians. According to early work in the area (circa 1970s), agreement between medicine and pharmacy was traditionally negotiated whereby those tasks viewed as repetitive and irreconcilable with the elevated status of doctors, were delegated to pharmacists (Eaton and Webb, 1979). In return, physicians would refrain from trespassing onto core pharmaceutical territory e namely drug dispensing (Eaton and Webb, 1979). While roles have shifted markedly over the course of the late 20th Century (cf. Mesler, 1991), what continues to define the relationship to pharmacy to medicine is medicine's prescribing power (Emmerton et al., 2005). Specifically, capacity to prescribe, continues to dominate boundary maintenance for medicine and in relation to pharmacy (Apesoa-Varano, 2013). While pharmacists are drug experts, doctors maintain significant professional control over drug decisions, largely through the enactment of prescribing power. A number of recent professional developments have challenged traditional medical dominance in relation to the pharmacy

profession. The move to greater involvement of pharmacy at the bedside, rather than as dispensers of medications, began in the 1970s and gathered significant momentum over the following four decades (Eaton and Webb, 1979). The clinical pharmacy movement, for example, has been articulated as the “ongoing negotiation of order in contemporary medicine” (cf Mesler, 1991: 311), reflecting its power in legitimising and expanding the pharmacy role (Rosenthal et al., 2014). In occupying this space pharmacists contend with many of the same challenges as physicians as they engage with patients, healthcare workers, and organisations while making ethical decisions (Chiarello, 2013: 320). Such shifts have been partnered with an international trend toward increasing prescribing rights for pharmacists (Emmerton et al., 2005; Makowsky et al., 2013; Pojskic et al., 2014; Rosenthal et al., 2014; Weiss and Sutton, 2009). In terms of the current study's focus, hospital pharmacy has evolved from supplying and managing antibiotics to holding key responsibilities in AMS programs and advising on antibiotic use (e.g. Hand, 2007). This has involved the emergence of AMS pharmacy as a professional speciality, with tasks including: giving expert advice; raising awareness of guidelines; enforcing formulary restrictions; and, auditing of antibiotic use (Hand, 2007). In this way antibiotic decisions represent an important site of interprofessional change in the basis of professional negotiations, including the potential reconfiguration of power and roles between medicine and pharmacy. 2.2. The Australian context The pharmacy profession is not linear across sectors or cultural contexts. For example, prescribing rights differ significantly internationally (Emmerton et al., 2005), with countries such as Canada, the UK, America and New Zealand recently extending (albeit limited) prescribing rights to pharmacists (Makowsky et al., 2013). In Australia, the prescribing dominance of doctors continues, but is increasingly being challenged by pharmacists (see PSA, 2010). Currently neither community or hospital pharmacists are able to prescribe antibiotics, yet they are increasingly tasked with their governance in institutions (ACSQHC, 2014). This includes responsibility for enacting formulary limits within hospitals guiding which antibiotics can be used, and by whom, shaping interprofessional relations. Public hospitals in Australia require an active AMS program in order to receive annual accreditation (ACSQHC, 2014). Bringing with it enhanced systematisation of antibiotic controls, and dedicated pharmacy input, AMS bolsters the potential role of pharmacists in influencing antibiotic decisions. Yet, and as reflected in the results below, the minutiae of antimicrobial governance and everyday practice may not be dictated by such guidelines and controls, limiting the potential power of pharmacy at a local level. We note that interprofessional dynamics in private hospital settings in Australia, where medical clinical practice is more autonomous and less regulated, may be significantly different than those presented below drawn from a public setting. 2.3. Borders, professional boundaries and moral gatekeeping The role of pharmacy in the hospital is quite specific in terms of professional power/autonomy and roles/expectations. As Chiarello argues, hospital pharmacists exercise less autonomous power than community pharmacists as the higher level of interaction and stronger relationships with other professionals increases their accountability and reduces flexibility. In the hospital context, direct patient interaction can be limited (i.e. number of pharmacists and capacity to provide direct advice to doctors ‘at the bedside’) which can result in a sense of disconnect from the social and cognitive context of the medication decision (Chiarello, 2013).

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Hospital pharmacists, given the particularities of their position, have been shown in previous studies to occupy certain ethical, organisational and moral roles, with responsibilities including those around cost effectiveness, risk management, public good and so forth (Chiarello, 2013). Given this, pharmacists can engage in practices of moral gatekeeping, upholding societal values by distributing resources in ways that reward those who comply with normative standards and punish those who do not (Chiarello, 2013). This in turn makes them prone to experiencing moral distress (see Jameton, 1984, 1993) due to their inability to implement all the actions they deem morally sound because they encounter institutional and interprofessional constraints (Chiarello, 2013: 325). Discussion of the moral and ethical dilemmas identified in the literature hitherto almost exclusively focuses on pharmacists intervening in contexts of: substance abuse; birth control; end-oflife care; or, drug unaffordability (see Hepler, 2003). Little attention to this point has been paid to antibiotic prescribing as a relational, moral and interprofessional problem. 2.4. Negotiations, asymmetries and positioning pharmacy within the hospital In considering pharmacy in the context of antibiotic decisions, work by Strauss et al. (1963) on hospital labour as a negotiated order provides a useful basis for beginning our exploration of interprofessional dynamics (Apesoa-Varano, 2013; Svensson, 1996). Strauss et al. (1963) pursued an ecological approach to the hierarchical relationships between professions, allowing a conceptualisation of occupations in spatial terms e that boundary encroachment is a potential threat to professional autonomy e an act of trespassing onto someone else's jurisdiction (see also Abbott, r, 2002). This involved recogni1988, 1995; cf. Lamont and Molna tion that an overlap between the duties of different occupational fields leads to the necessity to renegotiate boundaries to solve practical problems (Abbott, 1988, 1995; see also Barley, 1986). Such boundary work we posit e and differentiating us from Abbott's observations e does not necessarily lead to lasting transformations of the hierarchical framework in which it is situated. Rather it allows exceptions to the rules in order to deal with the challenge at hand and as such combines the potential for conflict with the certainty of its resolution (Strauss et al., 1963). The idea of ‘the negotiation’, in terms of making sense of how things are accomplished in healthcare organisations (Jameton, 1984, 1993), acknowledges that individual action and organisational constraint operate concurrently within negotiations, and in turn reflect forms of agency, power and resistance (Strauss, 1978; Svensson, 1996). From a negotiated order perspective, antibiotic use will in all likelihood involve practices of bargaining, compromising, the development of tacit understandings, and processes of exchange between professionals (Jameton, 1984, 1993). As an example, likely infection severity, relative risk of antibiotic use or non-use, and level of immediate infection risk, can be viewed as the product of on-the-ground negotiations, inflected by personalities, subjectivities and interpersonal dynamics. As Strauss (1978) argued, not all aspects of an organisation are continually subject to negotiation, rather, negotiations become prominent in contexts where lines of action or roles are uncertain. The dynamic of uncertainty is clearly manifest in the context of antibiotics and infection management more broadly, and in the evolving role of pharmacy therein. 3. Methods We employed a qualitative inductive approach, using semistructured interviews to investigate the experiences of

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pharmacists involved in the delivery of antibiotics at two hospitals in Queensland, Australia. Once ethics approval was granted (#2013000029) the study was advertised to all pharmacists working at the two hospitals. Over 90% (n ¼ 29) of the contacted pharmacists agreed to participate. Participants were not paid for participation and informed consent was gained for each interview. The researchers (AB and EK) visited the hospitals on a series of scheduled days in mid-2014, and completed interviews with all available participant volunteers. Nineteen of the pharmacists were available during the scheduled fieldwork days. The researchers agreed following completion and analysis of the 19 interviews that data saturation had been reached e that is, we had reached the point when no new themes were emerging related to the foci of the research. The sample included a range of early career, mid-career and senior pharmacists as well a gender split (12 females and 7 males). The interviews focused on: pharmacists' views on antibiotic use and resistance; the role of pharmacists within the hospital regarding antibiotics; professional and interprofessional issues; and, governance and organisational dynamics. Here we focus -vis medical or other exclusively on pharmacists' experiences (vis-a non-medical stakeholders) and on pharmacists working in the public health system. For work by the authors examining doctors' perspectives see Broom et al. (2014). 3.1. Analysis The methodology for this project sits within the interpretive traditions in sociology (Corbin and Strauss, 2008). The aim was to achieve a detailed understanding of the varying positions adhered to, and to locate these within a spectrum of broader underlying beliefs, agendas and life experiences (Charmaz, 2014). The approach to data collection was developmental in that knowledge generated in early interviews was challenged, compared with, and built upon by later insights and experiences. This method provided an opportunity to establish initial themes and then search for deviant or negative cases, complicating our observations and retaining the complexity of the data. We approached the analysis by conducting an initial thematic analysis, writing notes and discussing ideas within the research team. Within this process, we continually sought to retain the richness of the respondents' experiences, documenting atypical cases, conflicts, and contradictions within the data. Upon identifying a theme we searched through all the interviews for other related comments, employing constant comparison to develop or complicate them. This process helped ensure that events initially viewed as unrelated could be grouped together as their interconnectedness became apparent. The final step involved revisiting the literature and seeking out conceptual tools that could be employed to make sense of the patterns that had emerged from the data. 4. Results 4.1. The significance of antimicrobial mis-use and resistance for pharmacists The interviews began with a discussion of pharmacy and the sensitivities within the profession to the broader problem of antimicrobial resistance and ongoing misuse within the hospital sector. The pharmacists had mixed views on the significance of antibiotic mis-use and the threat of antimicrobial resistance. Their accounts tended to focus on the low awareness of, or concern for, resistance amongst pharmacists within the hospital and the tendency to get “bogged down in the particular case” [Mid-career, Female] rather than consider the broader picture of diminishing resources:

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I: Amongst pharmacists how much acknowledgement [is there that] there's a direct relationship between the usage of antibiotics and our eventual problem of resistance … P13: … we haven't talked about it that much … we actually, we don't talk [about it] … I don't think about the long-term effects very much, especially when that first order [for antibiotics] is there …. I just think about then and there, the patient. [Midcareer, Female] Another respondent: P1: … So [resistance] it's something, if something's not affecting you straightaway you tend to put it off and put it off and I think that's sort of what's happened, is what happens. I: Is that a pharmacy mentality as well? P1: … I think we just need to have the confidence to question things … like we do realise that there's a problem with risk [and resistance]. But what we can do about that I don't really know how much impact pharmacy can have. [Early Career, Female]

antibiotic use. The lack of consistent approach also meant that if one pharmacist acted as gatekeeper, while the others did not, those who tried to hold the line would be perceived negatively. This conflict of accountability meant that, while they considered themselves technically responsible for safeguarding antibiotics, they were not given specific techniques for achieving this (or indeed, that the available techniques were delimited by power relations). This resonates with Kellogg's (2011) observations of how the peculiarities of organisational and professional culture limits the adoption of regulatory change. Discussion in the interviews centred on having only technical accountability for antibiotics, and having significant ambivalence around “our level of professional responsibility” [Mid-career, Female]. Much of this ambivalence toward engaging professionally in antibiotic decisions was reconciled with the pervasiveness of medical prescribing power, and the tendency, as will be shown below, to delegate ultimate responsibility to doctors within this context.

4.2. Ascribing (medical) responsibility and prescriber power

Another respondent: P4: … I just think in the grand scheme of things how much effect is it having, or how much protection of antibiotics and reduction of resistance is it actually creating? … overall, [resistance] it's not something we sit around the lunch table talking about.… [Early Career, Male] As shown above, and in a number of other accounts, the participants questioned the attention paid toward antibiotic mis-use and the proliferation of resistance in their everyday work. There accounts illustrated a conflict between balancing the individual case, fiduciary responsibility and broader public health. Their reflections on the relative insignificance of antibiotic mis-use and proliferating resistance were couched in terms of not having the professional capacity to do anything or being “not properly listened to” [Mid-career, Female]. As self-described non-prescribers, this initial question about the significance of optimising antibiotic use was rationalised in terms of the perceived degree of professional control over, and responsibility for, the problem. Although a distinct minority, other participants did consider pharmacy to be responsive to antibiotic misuse and the rising problem of the proliferation of antimicrobial resistance: I: How seriously do you think pharmacy takes antibiotics … relative to other decisions? P3: I think they [pharmacists] take it [antibiotic misuse] very seriously. I think they love to get involved. Pharmacists tend to be number crunchers with statistics and precise dosing and calculators, [and antibiotics] falls right into our lap. [Senior, Male] Another respondent: P8: … we're probably somewhere in the middle of the spectrum … We'd be a bit more thinking of resistance, but also realising what was the urgency of the situation, the sickness of the patient … if the patient is febrile and the nurses are saying they've written this up it's urgent … the nurses would definitely pressure us to “just supply it now.” [Early-career, Female] As evident in these two participants' accounts, there was some divergence in perspectives across the participants. Such inconsistency was in turn talked about as a weakness of pharmacy in terms of capacity to prompt cross-organisational improvements in

While we did not structure the interview schedule around doctors, dialogue in the interviews was often situated around the extent to which doctors were responsible for prompting change versus pharmacists. For the majority of those interviewed, while there existed a nebulous notion of antibiotic optimisation as a collective responsibility and a joint decision in day-to-day hospital work, it was not internalised as the responsibility of pharmacists, even if it was partially a pharmacist's job to impose strategies and procedures to streamline usage. This, as it emerged, was largely due to the perceived omnipotence of doctors' prescribing power: P4: I'm not a prescriber … I: … who owns the decision, do you know what I mean? Like when an antibiotic gets to a patient…? P4: I think if the pharmacist has reviewed it on the ward, well, then yes, I think some responsibility … But … more of that responsibility still has to fall with the doctor who is still actually prescribing it … I'm not trying to say that it's all them … [Earlycareer, Male] Another respondent: P5: Because you're dealing with people who prescribe and as you as a non-prescriber are asking them to come on board, you're needing to move them [doctors], and you can't move them in front of each other because there's too much at stake [for them]. [Senior, Female] As shown above, there exists a range of interpersonal and power dynamics influencing pharmacists' self-perceptions about their role within antibiotic decisions. The primary dynamic is one of being non-prescribers and the fact that antibiotic decisions are viewed as a medical decision. Moreover, in contexts whereby the pharmacists aimed to intervene in antibiotic choices, they recounted other interpersonal dynamics (i.e. status issues between doctors, nursing interpersonal pressure, and so on) that reduced their capacity to enforce antibiotic guidelines and correct what they perceived as medical errors. In such situations, as one participant articulated, “there's still the pressure [on us] that ‘I need an antibiotic [now]’ …” [Early-career, Female]. Medical prescribing power combined with interpersonal pressure created a dynamic whereby the majority of the pharmacists felt limited capacity to change antibiotic practices even if the prescription was clearly incorrect.

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One solution often discussed was to extend beyond their medication focus and be more engaged (with doctors and patients) at the bedside for the initial diagnosis and/or treatment decision: P3: … when I first did pharmacy I was told that the job is to be an expert on drugs. That's it. So we're experts on antibiotics, but we're not experts on the diagnostics or the disease state … I've now found myself going in on the ward round and having a look at the skin, having a look at the eyes, and I pick things up … So in that regard you'd need to meet the medical teams halfway, at least halfway … but if you've got a serious situation, a person with multiple infections, multiple infection sites, you need to be careful that you're not jumping in … [pharmacy is] a changing role … [Senior, Male] Another respondent: P7: … sometimes I feel a bit uncomfortable when I'm saying “well, I think this,” and the junior doctor's saying “yep, yep, yep” and just writes verbatim what I'm saying and I'm saying “hang on … this is my recommendation, but I'm only looking at the drug portion of the patient, there may be other factors that I'm not aware of that make that therapy inappropriate.” So it's sort of a fine balance … Even though I know I'm probably right, at the back of my head I'm like “well, I haven't actually physically assessed the patient.” That's not part of my jurisdiction. [Midcareer, Female] These excerpts reflected the blurring of, and practices of reasserting, professional jurisdictions. The pharmacists were keen to disrupt their (self-described) reductive drug stance and to intervene directly in antibiotic decisions at the bedside to avoid correcting decisions later and thus being perceived as playing a policing role. Yet, this prompted a problematic overlap in professional roles, complicated by medical hierarchies (i.e. uncertain junior doctors desiring input from anyone who is informed around them), and disrupting the (fragile) boundaries between the expertise of pharmacy and medicine. The result was discomfort when providing advice at the bedside to junior doctors, with this act pushing pharmacy beyond their professional remit. Herein lies the complexity of blurred roles in clinical contexts, in turn resulting in the re-delegation of jurisdiction back to medical personnel. According to the participants the junior doctor (and by proxy the senior consultant) accepts additional input from the pharmacist e regardless of whether it blurs boundaries e for the purpose of professional survival and immediate patient wellbeing. And, the pharmacist accepts the new jurisdiction but ultimately retreats back to their position as focused on the medication issues. Within this complex decision-making dynamic there were aspects of antibiotic decisions deemed more acceptable for pharmacy to have jurisdiction over, and other areas in to which pharmacists were not allowed to encroach or intervene.

4.3. Hierarchies of decisions and medical hierarchies Decisions about antibiotics involve complex and ongoing considerations about dose, duration, de-escalation, mode of delivery (i.e. IV versus oral) as well as choice of antibiotic (i.e. broad versus narrow spectrum options) pre and post microbiology results. While the need to protect and restrict use of broad spectrum antimicrobials has been emphasised in recent years, other facets of antibiotic decisions are also crucial for patient outcomes and retaining the long-term integrity of antibiotics. The pharmacists revealed in the interviews that it was acceptable for them to make suggestions about dosage or duration, as they were considered by the medical

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staff to be non-critical matters. There was a hierarchy of areas of antibiotic decisions, and the pharmacists talked about being regularly ignored in contexts where they were deemed to have overstepped the demarcation of authority: P5: Antibiotic dosing advice [from pharmacy is] alright because that's sort of like seen as “yeah, you can do that”. That was never an issue. But it was more choice of antibiotic that I wanted to have a say in. I found that very frustrating. [Senior, Female] Another respondent: P7: [With some antibiotic misuse] who cares, yeah. That's where you have to have your graded assertiveness … I feel you've got to pick your battles. And unfortunately you can't fight every battle … [Mid-career, Female] Another respondent: I: Of [the incorrect antibiotic scripts] you pull up, how many would be changed to what you suggest? P12: Well, I guess it's hard because it probably depends. 25e30% max maybe … They [doctors] ignore a lot of our advice, because they think they know more, they don't have time to fix it. By the time they read, or come across, they're like “well, they've already had two days of it, and it's working, so let's continue it.” That's a big one, “it's working.” It's not a good reason. [Midcareer, Female] There emerged a distinct hierarchy of decisions in the context of antibiotics, with dosage viewed as pharmacy-relevant and in turn by medical staff as not particularly important (as perceived by the pharmacists). Advice deemed outside the pharmacy remit was talked about in the interviews as “likely to be ignored” [Mid-career, Female], resulting in a significant proportion of pharmacy corrections post-prescriptions not being actualised. Reflecting previous work on doctors' accounts of antibiotic prescribing (Broom et al., 2014), the pharmacists emphasised the interplay of medical hierarchies and their capacity to shift antibiotic use: P12: … you've got a registrar [junior, non-specialist doctor] that prescribes an inappropriate [antibiotic] choice and a consultant who is really keen [on that antibiotic], he'll tell the registrar “no, that's not right, we should do this.” And that registrar, knowing he [sic] wants to keep a good reputation, will change their practice. At least for that rotation … And if they moved to another area and it's slightly different then they'll do the right thing for that area. But at the moment if Dr so-and-so, head honcho does something weird, who's to argue? … [Mid career, Female] Another respondent: P2: … So you have the level or hierarchy if you will. The consultant … say “chart this.” And often the dose is not even relayed to the junior doctors. So it's up to them, and they're only a year or two years out, to make these therapeutic decisions that can have a huge effect on the patient's outcome during hospital. And sometimes when the advice comes from the consultant it's not necessarily correct advice. [Senior, Male] Another respondent: P7: … with that hierarchical system that exists in the medical profession, like sometimes depending on the consultant, even if the junior doctor knows all the stuff about the Antimicrobial stewardship, they may not feel comfortable [saying something]. [Mid-career, Female]

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As mentioned regarding a negotiated order, not all aspects of decisions are equally open to negotiation (i.e. antibiotic choice versus dose/duration), and moreover, interprofessional negotiations take place within a distinct hierarchical environment whereby various stakeholders (i.e. junior medical staff and pharmacists) actively position themselves in order to survive/ succeed within the given system and social world. Professional territories are thus demarcated by hierarchies of decisions and professional hierarchies. As shown elsewhere, the threat of not ‘playing the game’ may be much greater than use of inappropriate antibiotics for a junior doctor, or indeed, questioning decisions made by their supervising senior doctor (Broom et al., 2014).

4.4. Challenging medicine and the enactment of pharmacy power The dynamics of questioning, and the negotiation of power within the hospital is not simply about the enactment of medical power. Rather, heath professionals individually and collectively negotiate power and authority, actively making decisions about what influence they can have in a given context, and in turn utilising available resources to ensure their expertise is enacted or at least documented. The pharmacists had mixed views on their level of power and the impact on antibiotic decisions within the hospital context. P1: … I think it's hard to go to doctors and say, because if it's on a broad spectrum it's hard to say “why are we doing this?” I guess. And I think it probably needs to come from our whole pharmacy department to create that change rather than an individual pharmacist… … I don't think any individual pharmacist is going to change [antibiotic prescribing]. [Early-career, Female] Another respondent: P3: … I'm quite happy to go along and talk about football and then say “well, what about that dose, what do you think?” and put the ball back in their court. I see the younger people [pharmacists] don't know how to do that. So, I actually get them [doctors] talking about it [antibiotics], and then you can put the “well, have you considered?” or “what about?” and “have you seen this?” And once you engage them in that way, it's much easier. But I think it comes with maturity. [Senior, Male] Although there were a range of different approaches, the dominant approach was to ease doctors into changing their antibiotic decisions. The pharmacists talked about packaging these conversations as informal advice, often not making their position explicit (i.e. that they considered the doctors' decision inaccurate). As illustrated in the statement “I'm quite happy to go along and talk about football …” [Senior, Male], antibiotic advice from pharmacists was often packaged within informal conversation, as optional advice, and not as directly challenging professional decisions and territory. Yet, others interviewed considered explicitly challenging doctors' decisions as not interpersonally difficult, and moreover, cited a new generation of pharmacists who felt more able to question medical work: P18: … it's not like I'm stepping out of my boundaries, it's my job. I'm willing to [question doctors], as long as I've reviewed it [the decision] so that I'm confident to actually give my advice, whether it's stating “you're wrong,” well, it's how you word things … [Early-career, Male] Another respondent:

P14: We were always taught you don't ever question, you don't ever say “you're wrong,” you don't go in with that kind of negative, armoured for battle. It's more of a “do you mind if we discuss why this is the case … But I suppose some [pharmacists] have that element where “I have power,” you know they play a bit of the power game, you know “oh I'm going to win this argument.” … a lot of [pharmacists] kind of like the power of the purple pen.1 It's very powerful! [Senior, Female] Above we can see accounts of the power of pharmacy emerge and yet another layer to the dynamics between pharmacy and medicine in the context of antibiotics. The linking of purple ink to documenting perceived medical errors was a powerful visual device for the pharmacists, and illustrated a permanent note of their professional opinion on medical decisions in the patient medical record. In a sense this absolved them of responsibility if ultimately the medical staff refused to change the antibiotic script as shown below: P5: … I guess getting doctors to move or change [an antibiotic decision], especially in public, they do not like to be wrong, and they need the perception of not being wrong … I think [our problems are] consultancy level driven … the registrar will generally change if you can quote books. I: How do you resolve it [if they don't change it]? P5: I guess you don't. You resolve it in the fact that you've talked to all the stakeholders, you've said everything you've wanted to say, and it's really in their court. [Senior, Female] Another respondent: P6: I would make sure that I show them [doctors] and make more of an effort to point it [antibiotic error] out to them physically. … I: And are they liable? If you've said “there's an error here” and they don't make changes? P6: It means that we're not liable.” [Early-career, Female] What we can see being played out here is the delimited power of pharmacy in the context of medical prescribing power, but in turn the subtle (and sometimes less subtle) enacting of professional and bureaucratic power. The results depart from the dynamics observed by Chiarello (2015) when she pointed out that pharmacists disclaim the discretion that they do actually have. In the case of antibiotics, pharmacists are eschewing discretion for another important reason e that exercising their discretion comes at too high a personal cost. Downplaying the consequences of antibiotic mis-use may thus be partially about wanting to avoid interprofessional confrontation. Such dynamics are indicative of an emerging tension between pharmacy as stewards of antibiotics versus policing medical decisions.

4.5. Antibiotic stewards or prescribing police? Perhaps the most challenging interprofessional dynamic reported by the pharmacists was the stereotyping, and perceived dismissive relations, evident with medical staff within the hospitals. As noted, all pharmacists write in purple ink on the patient records and in drug request forms. While talked about as

1 The purple inked pen is utilised by pharmacists across many Australian hospitals.

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transmitted through rumour, and often indirectly, the pharmacists considered themselves to be often positioned in a negative light, represented as obstructive or even ridiculed: P12: … there's all this push on pharmacy … to do all this stuff [with antibiotics] but it's not coming down from the medical side. In my opinion I don't think there's ever been a strong push from medicine … to improve things from their end … You know what they [doctors] call us? “The purple pen Nazis.” … or “the purple pens of death.” … You call someone [a doctor], they hang up on you … “So trivial I don't have time for that.” [Mid-career, Female] Another respondent: P1: [Correcting antibiotic prescribing is] like you're dobbing [informing against someone]. And someone actually said “oh, I wondered how [infectious diseases] knew, it's been you dobbing on us.” … I don't know if doctors are 100% receptive to it [antibiotic guidance]. They probably just see it as another annoying pharmacy thing. You know, because we're always telling them what's wrong … [Junior, Female] The perception of playing a policing role weighed heavily on the pharmacists within the interviews, and was perceived as a major barrier to antibiotic optimisation and delimiting the effectiveness of pharmacy. As the self-described ‘go-betweens’ between infectious diseases (ID) physicians e who approve use of restricted broad spectrum antibiotics e and other medical staff, the pharmacists talked about being problematically situated within an intra-medical dynamic. A pertinent example was the ID-imposed stop-orders on broad spectrum antibiotics (i.e. broad spectrum antibiotic use is discontinued, if after 24 hours, ID approval has not been obtained). The power of Infectious Diseases physicians in restricting antibiotics resulted, according to these pharmacists, in some hospital departments storing antibiotics on their wards in order to have supplies in case ID approval was not forthcoming. Such dynamics placed pharmacy in a position whereby they had increased bureaucratic power but with increased interprofessional conflict. Such organisational governance practices and medical responses to new bureaucratic controls, contribute to the sense of -vis advising or supporting decisions. pharmacists as policing vis-a Combined with the perception of their policing as focused on “just another mundane issue …” [Mid-career, Female], as one participant articulated it, the impact of pharmacists on improving antibiotic practices was perceived as significantly limited. These role-based dynamics were in turn viewed as heavily dependent on organisational support and local economic investment in pharmacy positions. Organisational environment was seen to significantly mediate pharmacy penetration at the point of decision-making (i.e. at the bedside, despite its jurisdictional complexities) and effective engagement of opinion leaders amongst the medical staff. P1: If [poor antibiotic prescribing] happens on a wide scale you're probably more inclined to not do anything about it because it's too hard … When you're looking on the ward at doses and that sort of thing, it probably is a little bit easier to say “hey, why are we doing this?” that sort of thing. But a lot of the time pharmacists don't see it until after it's already happened, it's too late, there's not a lot you can do about it. [Early-career, Female] Another respondent: P9: But because the [pharmacy staff] allocation is probably insufficient because [and] they don't have the time, they're

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actually not there at the beginning of the patient journey, which is the prescribing … And then they become almost the policeman type role … [it is] the allocation of pharmacists per patient number … [Senior, Female] Another respondent: P2: … we're understaffed, not being on the ward all the time, not developing those relationships with those doctors, it's hard for them to listen to you. I find if I've been on a ward for some time … they're far more willing to listen to you. [Senior, Male] Another respondent: P5: … There's no point in educating and telling pharmacists that “now we have an antibiotic guideline and you need to change this and this.” When no one's bothered to tell the doctors what they should be writing … I guess you [need to] make [doctors and pharmacists] equal stakeholders … [Senior, Female] Antibiotic decisions, and the role of pharmacy therein, were viewed as mediated by a range of interprofessional, resourcing and organisational dynamics, with perceptions of pharmacy as meddling in medical decisions reinforced by the lack of organisational support for pharmacy to provide significant input on the wards and at the bedside. The dominant position within the interviews was that being perceived of being stewards and advisers versus police or critics was central to efforts to shift practices within the hospital. 5. Discussion Much emphasis has been placed on doctors as prescribers (Broom et al., 2014, 2015), despite the fact that antibiotic decisions are situated within interprofessional relations, engrained and evolving power dynamics, and shifting jurisdictions within the social world of the hospital. Interprofessional negotiations therein will fundamentally influence how antibiotics are used. Our analysis illustrates that antibiotic use may be heavily influenced by interprofessional power relations, jurisdictional disruptions and practices of reputational protection. With the rise of pharmacy as the new ‘antibiotic stewards’, we posit that the social relations illustrated here will prove critical in attempts to moderate usage across the hospital sector. In terms of antibiotics-as-negotiation, processes of bargaining and compromise were evident within these pharmacists' accounts e relational processes necessarily shaped by the dynamics of medical hierarchies and perceptions of a hierarchy of antibioticrelated decisions. Uncertainty e whether from a lack of experience on the part of junior doctors or lack of knowledge of antibiotic options more generally e meant that pharmacy was able to occupy a more active role in certain aspects of antibiotic decision-making. Given this, we posit that hospital pharmacists occupy a position of delimited negotiators e actors operating within a quickly changing social context holding entrenched and emerging asymmetries (cf. Strauss et al., 1963; Strauss, 1978). Moreover, that as antimicrobial stewardship programs take hold within the hospital environment, and as antibiotics become an increasingly urgent issue, pharmacists are experiencing jurisdictional gains (i.e. greater input, including at the bedside) but are in turn fundamentally limited by medical prescribing power and organisational structures. The introduction of pharmacy-directed bureaucratic controls over antibiotics (e.g. automatic stop orders) as part of antimicrobial stewardship introduces new forms of technical power e and capacity to intervene in medical decisions e but also raises new conflicts and strategies to reclaim professional authority over decisions.

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Antibiotics raise unique questions about the moral bases of interprofessional constraint. In other documented cases where pharmacists have been known to face challenges and even intervene e including narcotics, emergency contraception or end-of-life care e their intervention is about concerns for the individual (e.g. Hepler, 2003). In contrast, antibiotic mis-use and the proliferation of antimicrobial resistance is about longer-term public health or concern for the collective. Add to this the fact that antibiotics are prescribed so regularly and what emerges is a unique scenario for interprofessional tension and even conflict around immediate versus long-term goals. While we witnessed hints of moral distress (Chiarello, 2013: 325) e particularly the inability to implement actions they deemed morally sound e professional, interprofessional and organisational constraints were used to rationalise the limited moral accountability of the pharmacist in the misuse of antibiotics. Further attempts at engagement around antibiotics at the point of decision e or at the bedside e were met in these hospital contexts with a perceived lack of resourcing and organisational support, thus further persuading the pharmacists that they could do relatively little about the problem. This, we argue, may represent a form of ego-defence or excusing condition within the current social condi-vis medical tions within which pharmacists are operating vis-a power (see also Jameton, 1993). This is not to say pharmacists do not exert significant professional and interprofessional power in this context. They regularly reported utilising professional and organisational practices (an example being, the “power of the purple pen”) to exert and formally document their expert positions regarding antibiotic decisions. However, considerable professional frustration was evident and so too was the practice of professional distancing from these very decisions. Given that even within this individual group there were significantly varied responses to the prospect of antibiotics being obsolete, or indeed, to the proliferation of multi-resistant organisms, it is possible that pharmacy is embarking on a process of rationalising their own, and their group's stance, according to current emerging socio-political circumstances. A current series of external events, including policy pressure around antibiotic prescribing, may be beginning to challenge the interprofessional order (however precarious) within the hospital setting, including jurisdictional agreements between medicine and pharmacy. The perceived actions of doctors within the hospital may in turn be interpreted as attempts at reinforcing the medical act of antibiotic use, thus reasserting antibiotic decisions as medical jurisdiction (see Abbott, 1988). This suggests that the problem of antibiotics is (partially) disrupting or reconfiguring the professionalisation projects of pharmacy and medicine (cf. SarfattiLarson, 1979). That is, antibiotic negotiations concurrently challenge the jurisdictional monopoly of medicine and the legitimacy of medical expertise in the context of infection management (cf. Lamont and Moln ar, 2002). The rise of antimicrobial stewardship programs across the hospital sector internationally will likely further enhance the interprofessional dynamics evident in this study, and will present major shifts in the practice of the individual pharmacist and dynamics of professional legitimacy. Given the results presented here, it seems likely that a range of strategies could be enacted to optimise antibiotic use in hospitals on the basis of emerging and entrenched interprofessional relations. Examples could include the formalisation of interprofessional discussions as a standard procedure in pharmacotherapy, or indeed, the systematic training of pharmacists on negotiation and conflict management skills as part of antimicrobial stewardship activities (see also Coenen et al., 2004). Further research will be necessary in order to reveal other facets of interprofessional dynamics (i.e. nurseedoctorepharmacy

relations) as well as observational data exploring real-time decision-making. There are of course broader issues being played out here beyond questions of antibiotics, including aforementioned embedded and persistent hospital medicineepharmacy relations. In many respects the analysis we present here reflects historical power relations within the hospital environment (Barley, 1986; Kellogg, 2011). Yet, we also note that these are being enacted within a dramatically shifting socio-cultural environment and a context of evolving local and global policy and practice priorities. Reassessing and responding to the contemporary undulations of interprofessional dynamics will be key to improving AMS initiatives and antibiotic governance practices in hospitals, and in turn contributing to the securing of antibiotics for future generations. Acknowledgements This research was funded by an Australian Research Council Linkage Grant LP140100020. References Abbott, A., 1988. The System of Professions. Univ. Chicago Press, Chicago. Abbott, A., 1995. Things of boundaries. Soc. Res. 62, 857e882. Apesoa-Varano, E., 2013. Interprofessional conflict and repair. Sociol. Perspect. 56, 327e349. ACSQHC, 2014. Antimicrobial Prescribing Practice in Australia. Sydney. Barley, S., 1986. Technology as an occasion for structuring. Adm. Sci. Q. 31 (1), 78e108. Broom, A., Broom, J., Kirby, E., 2014. Cultures of resistance? A Bourdieusian analysis of doctors' antibiotic prescribing. Soc. Sci. Med. 110, 81e88. Broom, A., Broom, J., Kirby, E., Adams, J., 2015. The social dynamics of antibiotic use in an Australian hospital. J. Sociol. http://dx.doi.org/10.1177/1440783315594486 [online early]. Cairns, K.A., Jenney, A.W., Abbott, I.J., et al., 2013. Prescribing trends before and after implementation of an antimicrobial stewardship program. Med. J. Aust. 198, 262e266. CDC, 2014. Core Elements of Hospital Antibiotic Stewardship Programs. Access: http://www.cdc.gov. Charmaz, K., 2014. Constructing Grounded Theory. Sage, London. Chiarello, E., 2013. How organizational context affects bioethical decision-making. Soc. Sci. Med. 98, 319e329. Chiarello, E., 2015. The war on drugs comes to the pharmacy counter: frontline work in the shadow of discrepant institutional logics. Law Soc. Inq. 40 (1), 86e122. Coenen, S., Van Royen, P., Michiels, B., Denekens, J., 2004. Optimizing antibiotic prescribing for acute cough in general practice. J. Antimicrob. Chemother. 54 (3), 661e672. Corbin, J.M., Strauss, A.L., 2008. Basics of Qualitative Research. Sage, Los Angeles, CA. Denzin, N., Mettlin, C., 1968. Incomplete professionalization: the case of pharmacy. Soc. Forces 46, 375e381. Eaton, G., Webb, B., 1979. Boundary encroachment. Sociol. Health Illn. 1, 69e89. Emmerton, L., Bessel, T., Nissen, L., Dean, L., 2005. Pharmacists and prescribing rights. J. Pharm. Pharm. Sci. 8, 217e225. Fridkin, S.K., Srinivasan, A., 2013. Implementing a strategy for monitoring inpatient antimicrobial use among hospitals in the United States. Clin. Infect. Dis. 1e6. Hand, K., 2007. Antibiotic pharmacists in the ascendancy. J. Antimicrob. Chemother. 60, i73ei76. Hepler, C., 2003. Balancing pharmacist's conscientious objections with their duty to serve. J. Am. Pharm. Assoc. 45, 434e436. Ingram, P., Seet, J., Budgeon, C., Murray, R., 2012. Point-prevalence study of inappropriate antibiotic use at a tertiary Australian hospital. Intern. Med. J. 42, 719e721. Infectious Diseases Society of America [IDSA], 2014. Promoting Antimicrobial Stewardship in Human Medicine. Access: http://www.idsociety.org/ stewardship_policy/. Jameton, A., 1984. Nursing Practice. Prentice-Hall, Englewood Cliffs, N.J. Jameton, A., 1993. Dilemmas of moral distress. AWHONN's Clin. Issues Perinat. Women's Health Nurs. 4 (4), 542e551. Kellogg, K.C., 2011. Challenging Operations. University of Chicago Press. r, V., 2002. The study of boundaries in the social sciences. Annu. Lamont, M., Molna Rev. Sociol. 28, 167e195. Makowsky, M., Guirguis, L., Hughes, C., Sadowski, C., Yuksel, N., 2013. Factors influencing pharmacists' adoption of prescribing. Implement. Sci. 8, 109. Mesler, M., 1991. Boundary encroachment and task delegation. Sociol. Health Illn. 13, 310e331. PSA, 2010. Principles for a National Framework for Prescribing by Non-medical Health Professionals. Access: www.psa.org.au/policies.

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