Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
Department of Anthropology, Faculty of Arts, University of Waterloo, Waterloo, Ontario, Canada.
Med Educ. 2018 Jun;52(6):605-619. doi: 10.1111/medu.13522. Epub 2018 Feb 15.
As part of their training, physicians are required to learn how to perform technical skills on patients. The previous literature reveals that this learning is complex and that many opportunities to perform these skills are not converted into attempts to do so by learners. This study sought to explore and understand this phenomenon better.
A multi-phased qualitative study including ethnographic observations, interviews and focus groups was conducted to explore the factors that influence technical skill learning. In a tertiary paediatric emergency department, staff physician preceptors, residents, nurses and respiratory therapists were observed in the delivery and teaching of technical skills over a 3-month period. A constant comparison methodology was used to analyse the data and to develop a constructivist grounded theory.
We conducted 419 hours of observation, 18 interviews and four focus groups. We observed 287 instances of technical skills, of which 27.5% were attempted by residents. Thematic analysis identified 14 factors, grouped into three categories, which influenced whether residents attempted technical skills on real patients. Learner factors included resident initiative, perceived need for skill acquisition and competing priorities. Teacher factors consisted of competing priorities, interest in teaching, perceived need for residents to acquire skills, attributions about learners, assessments of competency, and trust. Environmental factors were competition from other learners, judgement that the patient was appropriate, buy-in from team members, consent from patient or caregivers, and physical environment constraints.
Our findings suggest that neither the presence of a learner in a clinical environment nor the trust of the supervisor is sufficient to ensure the learner will attempt a technical skill. We characterise this phenomenon as representing a pool of opportunities to conduct technical skills on live patients that shrinks to a much smaller pool of technical skill attempts. Learners, teachers and educators can use this knowledge to maximise the number of attempts learners make to perform technical skills on real patients.
作为培训的一部分，医生需要学习如何在患者身上实施技术技能。先前的文献表明，这种学习是复杂的，而且学习者并没有将许多实施这些技能的机会转化为实际的尝试。本研究旨在更深入地探讨和理解这一现象。
本研究采用多阶段定性研究方法，包括民族志观察、访谈和焦点小组，以探讨影响技术技能学习的因素。在一家三级儿科急诊部门，在 3 个月的时间里，观察了主治医生导师、住院医生、护士和呼吸治疗师在技术技能的传授和教学中的情况。采用恒比法对数据进行分析，并建立一个建构主义扎根理论。
我们进行了 419 小时的观察、18 次访谈和 4 次焦点小组。我们观察了 287 次技术技能，其中 27.5%是住院医生尝试的。主题分析确定了 14 个因素，分为三类，这些因素影响了住院医生是否在真实患者身上尝试技术技能。学习者因素包括住院医生的主动性、对技能获取的需求以及竞争的优先事项。教师因素包括竞争的优先事项、对教学的兴趣、对住院医生获得技能的需求、对学习者的归因、对能力的评估、以及信任。环境因素包括来自其他学习者的竞争、判断患者是否合适、团队成员的支持、患者或照顾者的同意，以及物理环境的限制。
我们的研究结果表明，学习者在临床环境中的存在以及主管人员的信任都不足以确保学习者会尝试实施技术技能。我们将这种现象描述为代表了在真实患者身上实施技术技能的机会之池，该机会之池缩小到尝试实施技术技能的机会之池。学习者、教师和教育者可以利用这一知识，使学习者在真实患者身上实施技术技能的尝试次数最大化。
