Farnan Jeanne M, Johnson Julie K, Meltzer David O, Harris Ilene, Humphrey Holly J, Schwartz Alan, Arora Vineet M
J Grad Med Educ. 2010 Mar;2(1):46-52. doi: 10.4300/JGME-D-09-00015.1.
Supervision is central to resident education and patient safety, yet there is little published evidence to describe a framework for clinical supervision. The aim of this study was to describe supervision strategies for on-call internal medicine residents.
Between January and November 2006, internal medicine residents and attending physicians at a single hospital were interviewed within 1 week of their final call on the general medicine rotation. Appreciative inquiry and critical incident technique were used to elicit perspectives on ideal and suboptimal supervision practices. A representative portion of transcripts were analyzed using an inductive approach to develop a coding scheme that was then applied to the entire set of transcripts. All discrepancies were resolved via discussion until consensus was achieved.
Forty-four of 50 (88%) attending physicians and 46 of 50 (92%) eligible residents completed an interview. Qualitative analysis revealed a bidirectional model of suggested supervisory strategies, the "SUPERB/SAFETY" model; an interrater reliability of 0.70 was achieved. Suggestions for attending physicians providing supervision included setting expectations, recognizing uncertainty, planning communication, having easy availability, reassuring residents, balancing supervision, and having autonomy. Suggested resident strategies for seeking supervision from attending physicians included seeking input early, contacting for active clinical decisions or feeling uncertain, end of life issues, transitions in care, or help with systems issues. Common themes suggested by trainees and attending physicians included easy availability and preservation of resident decision-making autonomy.
Residents and attending physicians have explicit expectations for optimal supervision. The SUPERB/SAFETY model of supervision may be an effective resource to enhance the clinical supervision of residents.
监督是住院医师培训和患者安全的核心，但几乎没有公开的证据来描述临床监督的框架。本研究的目的是描述内科住院医师值班期间的监督策略。
2006年1月至11月期间，在一家医院的内科住院医师和主治医师完成普通内科轮转最后一次值班后的1周内接受了访谈。采用肯定性探究和关键事件技术来获取关于理想和次优监督实践的观点。使用归纳法对部分有代表性的访谈记录进行分析，以制定编码方案，然后将其应用于全部访谈记录。所有差异均通过讨论解决，直至达成共识。
50名主治医师中有44名（88%）、50名符合条件的住院医师中有46名（92%）完成了访谈。定性分析揭示了一种双向的监督策略模型，即“SUPERB/SAFETY”模型；评分者间信度达到了0.70。为主治医师提供监督的建议包括设定期望、认识到不确定性、规划沟通、随时可及、让住院医师安心、平衡监督以及给予自主权。住院医师向主治医师寻求监督的建议策略包括尽早寻求意见、就积极的临床决策或感到不确定时联系、临终问题、护理过渡或系统问题方面寻求帮助。住院医师和主治医师提出的共同主题包括随时可及和保留住院医师决策自主权。
住院医师和主治医师对最佳监督有明确的期望。SUPERB/SAFETY监督模型可能是加强住院医师临床监督的有效资源。
