为执业医生提供补救方案,以恢复病人的安全:restore现实主义检讨

Tristan Price, N. Brennan, G. Wong, L. Withers, J. Cleland, A. Wanner, T. Gale, L. Prescott-Clements, J. Archer, M. Bryce
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引用次数: 6

摘要

一个表现不佳的医生会危及病人的安全。补救是一种干预措施,旨在解决表现不佳的问题,并使医生回到安全的做法。在世界各地的卫生保健系统中使用,它对患者安全和医生在劳动力中的保留都有明显的影响。然而,支持补救方案的证据有限,特别是缺乏关于补救干预为什么以及如何改变医生执业的知识。目的(1)对文献进行现实的回顾,以确定执业医生的补救方案为什么、如何、在什么情况下、为谁以及在多大程度上恢复患者安全;(2)为医生的补救措施提供针对性、实施和设计策略建议。设计以现实主义和元叙事证据综合:不断发展的标准、质量和报告标准为基础的文献现实主义综述。数据来源2018年6月检索书目数据库:EMBASE、MEDLINE、护理与相关健康文献累积索引、PsycINFO、教育资源信息中心、疗效评价摘要数据库、应用社会科学索引与摘要数据库、健康管理信息联盟数据库。灰色文献检索于2019年6月进行,使用如下:谷歌Scholar(谷歌Inc., Mountain View, CA, USA)、OpenGrey、英国NHS、North Grey文献收集、国家卫生与护理卓越证据研究所、电子论文在线服务、卫生系统证据和将研究转化为实践。通过逆向引文检索、核心研究团队图书馆检索和利益相关者小组检索,进一步确定相关研究。审查方法现实主义审查是一种以理论为导向的解释证据的综合方法,旨在发展有关干预如何产生其效果的计划理论。我们通过召集一个利益相关者团体并对文献进行系统的搜索,开发了一个补救方案理论。我们纳入了所有关于执业医生补救的英语研究、所有研究设计、所有卫生保健环境和所有结果测量。我们摘录了与程序理论有关的文本段落。提取的数据然后使用现实分析逻辑进行综合,以确定上下文-机制-结果配置。结果共纳入141条记录。在纳入综述的141项研究中,64%与北美有关,14%来自英国。大多数研究(72%)发表于2008年至2018年之间。总共有33%的文章是评论,30%是研究论文,25%是案例研究,12%是其他类型的文章。在研究论文中,定量法占64%,文献综述法占19%,定性法占14%,混合法占3%。总共有40%的文章是关于初级医生/住院医生的,31%是关于执业医生的,17%是关于两者的混合(其中一些包括医学生),12%的文章不适用。总共有40%的研究侧重于纠正临床实践的所有领域,包括医学知识、临床技能和专业精神。总共有27%的研究只关注专业性,19%的研究关注知识和/或临床技能,14%的研究没有具体说明。总共有32%的研究描述了一种补救措施,16%概述了设计补救方案的策略,11%概述了补救模式,41%不适用。确定了29种情境-机制-结果配置。当补救方案培养医生的洞察力和动机,并加强行为改变时,它们就会起作用。提供安全空间、倡导在补救过程中建立信任以及精心构建反馈等策略,创造了心理安全和专业失调导致洞察力发展的环境。让补救医生参与补救计划可以在过程中提供一种感知的控制感,这与纠正因果归因、设定目标、消除补救的污名和明确后果一起,有助于激励医生做出改变。通过练习新的行为和技能以及通过有指导的反思,可以促进持续的变化。局限性:纳入文献的质量低,英国研究的数量有限。未来的工作未来的工作应该使用的建议,以优化现有的补救方案交付的医生在NHS。研究注册本研究注册号为PROSPERO CRD42018088779。 该项目由国家卫生研究所(NIHR)卫生服务和交付研究方案资助,将全文发表在《卫生服务和交付研究》上;第9卷第11期请参阅NIHR期刊图书馆网站了解更多项目信息。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Remediation programmes for practising doctors to restore patient safety: the RESTORE realist review
Background An underperforming doctor puts patient safety at risk. Remediation is an intervention intended to address underperformance and return a doctor to safe practice. Used in health-care systems all over the world, it has clear implications for both patient safety and doctor retention in the workforce. However, there is limited evidence underpinning remediation programmes, particularly a lack of knowledge as to why and how a remedial intervention may work to change a doctor’s practice. Objectives To (1) conduct a realist review of the literature to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety; and (2) provide recommendations on tailoring, implementation and design strategies to improve remediation interventions for doctors. Design A realist review of the literature underpinned by the Realist And MEta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards. Data sources Searches of bibliographic databases were conducted in June 2018 using the following databases: EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Education Resources Information Center, Database of Abstracts of Reviews of Effects, Applied Social Sciences Index and Abstracts, and Health Management Information Consortium. Grey literature searches were conducted in June 2019 using the following: Google Scholar (Google Inc., Mountain View, CA, USA), OpenGrey, NHS England, North Grey Literature Collection, National Institute for Health and Care Excellence Evidence, Electronic Theses Online Service, Health Systems Evidence and Turning Research into Practice. Further relevant studies were identified via backward citation searching, searching the libraries of the core research team and through a stakeholder group. Review methods Realist review is a theory-orientated and explanatory approach to the synthesis of evidence that seeks to develop programme theories about how an intervention produces its effects. We developed a programme theory of remediation by convening a stakeholder group and undertaking a systematic search of the literature. We included all studies in the English language on the remediation of practising doctors, all study designs, all health-care settings and all outcome measures. We extracted relevant sections of text relating to the programme theory. Extracted data were then synthesised using a realist logic of analysis to identify context–mechanism–outcome configurations. Results A total of 141 records were included. Of the 141 studies included in the review, 64% related to North America and 14% were from the UK. The majority of studies (72%) were published between 2008 and 2018. A total of 33% of articles were commentaries, 30% were research papers, 25% were case studies and 12% were other types of articles. Among the research papers, 64% were quantitative, 19% were literature reviews, 14% were qualitative and 3% were mixed methods. A total of 40% of the articles were about junior doctors/residents, 31% were about practicing physicians, 17% were about a mixture of both (with some including medical students) and 12% were not applicable. A total of 40% of studies focused on remediating all areas of clinical practice, including medical knowledge, clinical skills and professionalism. A total of 27% of studies focused on professionalism only, 19% focused on knowledge and/or clinical skills and 14% did not specify. A total of 32% of studies described a remediation intervention, 16% outlined strategies for designing remediation programmes, 11% outlined remediation models and 41% were not applicable. Twenty-nine context–mechanism–outcome configurations were identified. Remediation programmes work when they develop doctors’ insight and motivation, and reinforce behaviour change. Strategies such as providing safe spaces, using advocacy to develop trust in the remediation process and carefully framing feedback create contexts in which psychological safety and professional dissonance lead to the development of insight. Involving the remediating doctor in remediation planning can provide a perceived sense of control in the process and this, alongside correcting causal attribution, goal-setting, destigmatising remediation and clarity of consequences, helps motivate doctors to change. Sustained change may be facilitated by practising new behaviours and skills and through guided reflection. Limitations Limitations were the low quality of included literature and limited number of UK-based studies. Future work Future work should use the recommendations to optimise the delivery of existing remediation programmes for doctors in the NHS. Study registration This study is registered as PROSPERO CRD42018088779. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.
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