Between heuristic and deliberative thinking: a multi-center qualitative study of physicians’ decision-making in infection prevention practice

Application of standard infection prevention and control (IPC) measures is crucial to prevent hospital-acquired infections, but compliance by physicians is suboptimal. Interventions aimed to improve compliance are often generic and lack sustained effects. A better understanding of physicians’ trade-offs regarding application of IPC and influences on their behavior is needed to develop effective behavior change interventions. We aimed to understand physicians’ decision-making processes around application of IPC and the factors that influence their behavior.

This qualitative study involved semi-structured interviews with 18 physicians and 7 nurses from five different hospitals in the Netherlands. Reflexive thematic analysis involved inductive coding followed by deductive analysis using mechanisms of action, including the Theoretical Domains Framework, that link to behavior change techniques.

We found heterogeneity in physicians’ approaches to decision-making around application of IPC. Some physicians relied on heuristics, while others applied logical reasoning. The latter group made an autonomous assessment of the risks for infection associated with a situation and traded off the costs and benefits of IPC application. The decision was further influenced by personal beliefs about the value of IPC and a supporting physical and social environment. Eighteen out of 26 mechanisms of action underlying the influences on IPC behavior were matched to our results; most important are “memory, attention and decision processes”, “behavioral cueing”, “beliefs about consequences”, “values”, “norms”, “social influences”, “social learning/imitation” and “environmental context and resources”. These findings suggest that interventions are most likely to be beneficial if these focus on developing heuristics, changing risk beliefs, using social norms and imitation and generating a supportive environment.

The heterogeneity in physicians’ decision-making and autonomous risk assessment which is different from other healthcare professionals calls for tailored interventions targeting heuristic decision making, personal beliefs, social norms and the environmental context.