Yardley Sarah, Cottrell Elizabeth, Rees Eliot, Protheroe Joanne
Primary Care and Health Sciences, Keele University, Keele, Staffs, ST5 5BG, UK.
BMC Fam Pract. 2015 Feb 25;16:23. doi: 10.1186/s12875-015-0234-9.
People are increasingly living for longer with multimorbidity. Medical education and healthcare delivery must be re-orientated to meet the societal and individual patient needs that multimorbidity confers. The impact of multimorbidity on the educational needs of doctors is little understood. There has been little critique of how learning alongside healthcare provision is negotiated by patients, general practitioners and trainee doctors. This study asked 'what is known about how and why concurrent healthcare delivery and professional experiential learning interact to generate outcomes, valued by patients, general practitioners and trainees, for patients with multimorbidity in primary care?'
This realist synthesis is reported using RAMESES standards. Relationship-centred negotiation of needs-based learning and care was the primary outcome of interest. Healthcare, social science and educational literature were sought as evidence. Data extraction focused on context, mechanism and outcome configurations within studies and on data which might assist understanding and explain; i) these configurations; ii) the relationships between them and; iii) their role and place in evolving programme theories arising from data synthesis. Mind-mapping software and team meetings were used to aid interpretative analysis.
The final synthesis included 141 papers of which 34 contained models for workplace-based experiential learning and/or patient care. Models of experiential learning for practitioners and for patient engagement were congruent, frequently referencing theories of transformation and socio-cultural processes as mechanisms for improving clinical care. Key issues included the perceived impossibility of reconciling personalised concepts of success with measurability of clinical markers or adherence to guidelines, and the need for greater recognition of social dynamics between patients, GPs and trainees including the complexities of shared responsibilities. A model for considering the implications of concurrency for learning and healthcare delivery in the context of multimorbidity in primary care is proposed and supporting evidence is presented.
This study is novel in considering empirical evidence from patients, GPs and trainees engaged in concurrent learning and healthcare delivery. The findings should inform future interventions designed to produce a medical workforce equipped to provide multimorbidity care.
PROSPERO International prospective register of systematic reviews CRD42013003862.
患有多种疾病的人寿命越来越长。医学教育和医疗服务必须重新定位，以满足多种疾病带来的社会和个体患者需求。人们对多种疾病对医生教育需求的影响了解甚少。对于患者、全科医生和实习医生如何协商在提供医疗服务的同时进行学习，几乎没有相关评论。本研究提出的问题是“关于在基层医疗中，同时进行医疗服务和专业实践学习如何相互作用并产生患者、全科医生和实习生都重视的结果，我们了解多少？以及为什么会这样？”
本现实综合研究按照RAMESES标准进行报告。以需求为基础的学习和护理的以关系为中心的协商是主要关注的结果。检索医疗、社会科学和教育文献作为证据。数据提取侧重于研究中的背景、机制和结果配置，以及可能有助于理解和解释的以下数据：i）这些配置；ii）它们之间的关系；iii）它们在数据综合产生的不断发展的项目理论中的作用和地位。使用思维导图软件和团队会议辅助进行解释性分析。
最终综合分析纳入了141篇论文，其中34篇包含基于工作场所的实践学习和/或患者护理模型。从业者的实践学习模型和患者参与模型是一致的，经常引用转变理论和社会文化过程理论作为改善临床护理的机制。关键问题包括：人们认为难以将个性化的成功概念与临床指标的可测量性或对指南的遵循相协调，以及需要更多地认识患者、全科医生和实习生之间的社会动态，包括共同责任的复杂性。提出了一个模型，用于考虑在基层医疗中多种疾病背景下同时进行学习和医疗服务的影响，并提供了支持证据。
本研究在考虑来自参与同时学习和医疗服务的患者、全科医生和实习生的实证证据方面具有创新性。研究结果应为未来旨在培养有能力提供多种疾病护理的医疗队伍的干预措施提供参考。
PROSPERO国际系统评价前瞻性注册库CRD42013003862
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