Table 3 Representative quotations for theme 1: Prescription preferences are influenced by perceptions, experience, training and guidelines

Perceived risk-benefit ratio

Beliefs about consequences/ Motivation and goals

“Early oral feeding is associated with a significant reduction specifically in septic or infective complications. There is a 20% increase in nausea and vomiting, however, but overall, the rate of postoperative ileus is actually decreased by early oral feeding and not increased” [P01: Consultant]

“Early post-op feeding is important… Probably the biggest study that was done was a meta-analysis that looked at I think… 14 or 15 studies, and there wasn’t any significant findings but there was certainly a trend towards a lot of reduced complications… so reduced anastomotic leak rate, reduced intra-abdominal abscesses, a trend towards early return of gut function… so they’re all pretty important things, and there was certainly no increase in complications…I mean whether it does any good…hard to know, the evidence is not strong…but it probably does. It certainly doesn’t do any harm… I guess it’s got other protective things like gut mucosa, and all of those sorts of things… so, you know… early oral feeding is important” [P03: Fellow]

“Nutrition, of course, is very important… but once the bowel starts working, once the bowel activity starts and the bowel continuity is ensured – once we are sure the anastomosis is intact, they should be going back to their normal diet. That is what we would like to see” [P14: Consultant]

“I would be scared commencing solids within 24 h in a lot of these patients who have this fresh join which could leak into the bowel [abdomen]” [P13: Intern]

Training and past behaviours

Nature of the behaviour/ Motivation and goals/ Skills

“I’m sure the guys who are very reluctant to start oral feeding early is just because that was the way they were taught and they haven’t had any issues with it, so why would they change. Whereas, I was taught, nah it’s ok to do that, and you’ve just got to be aware of if they’re heading in the wrong direction, and when to cut back on their oral intake” [P10: Consultant]

“I suppose I have been exposed to the earlier practices where people were… fasted for a week...when I first started training. But as I became more senior I was exposed to more ERAS protocols in sub-speciality training with earlier feeding... so I was introduced to the concept of earlier feeding” [P15: Consultant]

“What I’ve seen is that there is definitely a change in the school of thought. I’m a junior registrar so I’m in the area that is quite different [to what it was previously]. The older surgeons are much more hold-offish. But the younger and more developing surgeons are...and definitely the fellows – they defiantly seem to be more on the front foot with nutrition after surgery” [P11: Principal House Officer]

“I’m surprised to hear that guidelines recommend commencing solid feeding within 24 h after surgery among lower gastrointestinal patients. That is interesting…because if on ward rounds the consultant the next day after surgery was like, ‘full diet’ I would be like ‘whoa, are you sure?’ Like, I would double check. Yeah, so that is surprising” [P13: Intern] (NB: This was in response to the interviewer sharing guideline recommendations with the participant)

Positive and negative experiences

Beliefs about consequences/ Nature of the behaviours/ Motivation and goals

“I was the clinical lead of the Enhanced Recovery After Surgery Program…we recorded data before the implementation of ERAS. There was quite a substantial reduction in morbidity and length of stay associated with the implementation of ERAS [P01: Consultant]

“Earlier this year, we had a few patients that [sic] had postoperative vomiting and had aspirations ... aspiration pneumonia and so from that there was a bit of a reflex action to recommend that we don’t push people’s oral intake as much ... [so there was] kind of reaction to those couple of complications” [P09: Fellow]