Sagasser Margaretha H, Fluit Cornelia R M G, van Weel Chris, van der Vleuten Cees P M, Kramer Anneke W M
M.H. Sagasser was educationalist and researcher, Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands, at the time of the study. The author is now educationalist and researcher, Huisartsopleiding Nederland, Utrecht, the Netherlands. C.R.M.G. Fluit is head, Center on Research in Learning and Education, Radboud University Medical Center Health Academy, Nijmegen, the Netherlands. C. van Weel is professor emeritus of general practice, Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands, and honorary professor of primary health care research, Department of Health Services Research and Policy, Australian National University, Canberra, ACT, Australia. C.P.M. van der Vleuten is professor of education and director, School of Health Professions Education, Faculty of Health, Medicine, and Life Sciences, Maastricht University, the Netherlands. A.W.M. Kramer is general practitioner, professor of general practice, and head, Family Medicine Residency Program, Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands.
Acad Med. 2017 Jun;92(6):792-799. doi: 10.1097/ACM.0000000000001464.
Entrustment has mainly been conceptualized as delegating discrete professional tasks. Because residents provide most of their patient care independently, not all resident performance is visible to supervisors; the entrustment process involves more than granting discrete tasks. This study explored how supervisors made entrustment decisions based on residents' performance in a long-term family medicine training program.
A qualitative nonparticipant observational study was conducted in 2014-2015 at competency-based family medicine residency programs in the Netherlands. Seven supervisor-resident pairs participated. During two days, one researcher observed first-year residents' patient encounters, debriefing sessions, and supervisor-resident educational meetings and interviewed them separately afterwards. Data were collected and analyzed using iterative, phenomenological inductive research methodology.
The entrustment process developed over three phases. Supervisors based their initial entrustment on prior knowledge about the resident. In the ensuing two weeks, entrustment decisions regarding independent patient care were derived from residents' observed general competencies necessary for a range of health problems (clinical reasoning, decision making, relating to patients); medical knowledge and skills; and supervisors' intuition. Supervisors provided supervision during and after encounters. Once residents performed independently, supervisors kept reevaluating their decisions, informed by residents' overall growth in competencies rather than by adhering to a predefined set of tasks.
Supervisors in family medicine residency training took a holistic approach to trust, based on general competencies, knowledge, skills, and intuition. Entrustment started before training and developed over time. Building trust is a mutual process between supervisor and resident, requiring a good working relationship.
委托主要被概念化为分配离散的专业任务。由于住院医师大多独立提供患者护理，并非所有住院医师的表现都能被上级看到；委托过程涉及的不仅仅是分配离散任务。本研究探讨了在长期家庭医学培训项目中，上级如何根据住院医师的表现做出委托决策。
2014 - 2015年在荷兰基于胜任力的家庭医学住院医师培训项目中进行了一项定性非参与观察性研究。七对上级 - 住院医师参与其中。在两天时间里，一名研究人员观察了一年级住院医师的患者诊疗过程、汇报会以及上级 - 住院医师教育会议，并在之后分别对他们进行了访谈。使用迭代的现象学归纳研究方法收集和分析数据。
委托过程分三个阶段发展。上级基于对住院医师的先验知识做出初始委托。在随后的两周内，关于独立患者护理的委托决策源自观察到的住院医师处理一系列健康问题所需的一般能力（临床推理、决策、与患者沟通）；医学知识和技能；以及上级的直觉。上级在诊疗过程中和之后提供监督。一旦住院医师能够独立操作，上级会不断根据住院医师能力的整体提升重新评估他们的决策，而不是拘泥于预先设定的一组任务。
家庭医学住院医师培训中的上级基于一般能力、知识、技能和直觉采取整体的信任方法。委托在培训前就已开始并随时间发展。建立信任是上级和住院医师之间的相互过程，需要良好的工作关系。
