Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
Department of Educational Development and Research, FHML, Maastricht University, Maastricht, The Netherlands.
Ann Surg. 2020 Feb;271(2):391-398. doi: 10.1097/SLA.0000000000003125.
The aim of this study was to explore how trust was constructed between surgeons and residents in the operating room.
Entrustment is increasingly being used as a key element to assess trainees' competence in the clinical workplace. However, the cognitive process involved in the formulation of surgical trust remains poorly understood.
In semistructured interviews, 9 general surgeons discussed their experiences in making entrustment decisions during laparoscopic cholecystectomy. Template analysis methodology was employed to develop an explanatory model.
Surgeons described the construction of trust as a stepwise process taking place before, during, and after the procedure. The main steps were as follows: (1) an initial propensity to trust based on the perceived risk of the case and trustworthiness of the resident; (2) a decision to initiate trust in the resident to begin the surgery; (3) close observation of preliminary steps; (4) an evolving decision based on whether the surgery is "on-track" or "off-track"; (5) intervention if the surgery was "off-track" (withdrawal of trust); (6) re-evaluation of trust for future cases. The main reasons described for withdrawing trust were: inability to follow instructions, failure to progress, and unsafe manoeuvres.
This study showed that surgical trust is constructed through an iterative process involving gathering and valuing of information, decision-making, close observation, and supervisory intervention. There were strong underlying themes of control and responsibility, and trust was noted to increase over time and over repeated observations. The model presented here may be useful in improving judgements on competence in the surgical workplace.
本研究旨在探讨外科医生和住院医师在手术室中是如何建立信任的。
委托授权越来越多地被用作评估临床工作场所受训者能力的关键要素。然而，手术信任形成的认知过程仍知之甚少。
在半结构化访谈中，9 名普通外科医生讨论了他们在腹腔镜胆囊切除术期间做出委托决策的经验。采用模板分析方法来开发一个解释模型。
外科医生将信任的构建描述为一个分阶段的过程，发生在手术前、手术中和手术后。主要步骤如下：（1）基于对病例风险和住院医师可信赖性的感知，初步倾向于信任；（2）决定开始信任住院医师以开始手术；（3）密切观察初步步骤；（4）根据手术是否“按计划进行”或“偏离计划”做出不断发展的决策；（5）如果手术“偏离计划”（撤回信任），则进行干预；（6）为未来的病例重新评估信任。撤回信任的主要原因是：无法遵循指令、无法取得进展和不安全的操作。
本研究表明，手术信任是通过一个迭代过程建立的，涉及信息收集和评估、决策、密切观察和监督干预。控制和责任是强有力的潜在主题，并且随着时间的推移和反复观察，信任会增加。这里提出的模型可能有助于提高对手术工作场所能力的判断。
