值得信赖的学习：实习医学生对临床学习环境中信任的定性研究。
Trusted to Learn: a Qualitative Study of Clerkship Students' Perspectives on Trust in the Clinical Learning Environment.
机构信息
School of Medicine, University of California, San Francisco, 513 Parnassus Ave, San Francisco, CA, 94143-0410, USA.
Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
出版信息
J Gen Intern Med. 2019 May;34(5):662-668. doi: 10.1007/s11606-019-04883-1.
BACKGROUND
Trust informs supervision decisions in medical training. Factors that influence trust differ depending on learners' and supervisors' level. Research has focused on resident trainees; questions exist about how medical students experience entrustment.
OBJECTIVE
This study examines how clerkship students perceive supervisors' trust in them and its impact on their learning.
DESIGN
Qualitative study using individual semi-structured interviews.
PARTICIPANTS
Clerkship medical students at the University of California, San Francisco.
APPROACH
We invited 30 core clerkship students to participate in interviews (October 2017 to February 2018) eliciting examples of appropriate, over-, and under-trust. We coded and analyzed transcripts using thematic analysis.
KEY RESULTS
Sixteen (53%) students participated. Three major themes arose: trust as scaffolding for learning, effects of trust on the learning environment, and consequences of trust for patients. Appropriate trust usually involved coaching and close guidance, often with more junior supervisors (interns or residents). These situations fostered students' motivation to learn, sense of value on the team, and perceived benefits to patients. Over-trust was characterized by task assignment without clear instruction, supervision, or feedback. Over-trust prompted student anxiety and stress, and concerns for potential patient harm. Under-trust was characterized by lack of clarity about the student role, leading to frustration and discontent, with unclear impact on patients. Students attributed inappropriate trust to contextual and supervisor factors and did not feel empowered to intervene due to concerns about performance evaluations and hierarchy.
CONCLUSIONS
As early learners in the clinical workplace, students frame trust as entailing high levels of support. It is important for medical educators to consider ways to train resident and faculty supervisors to enact trust and supervision for students differently than for residents. Structures that encourage students and supervisors to discuss trust and supervision in a transparent way can enhance learning.
背景
信任影响医学培训中的监督决策。影响信任的因素因学习者和监督者的级别而异。研究集中在住院医师培训者身上；关于医学生如何体验委托，存在一些问题。
目的
本研究考察了实习医学生如何看待他们的监督者对他们的信任，以及这种信任对他们学习的影响。
设计
使用个体半结构化访谈的定性研究。
参与者
旧金山加利福尼亚大学实习医学生。
方法
我们邀请了 30 名核心实习医学生参加访谈（2017 年 10 月至 2018 年 2 月），引出适当、过度和不足信任的例子。我们使用主题分析对转录本进行编码和分析。
主要结果
16 名（53%）学生参与。出现了三个主要主题：信任作为学习的支架、信任对学习环境的影响以及信任对患者的后果。适当的信任通常涉及指导和密切指导，通常是由更初级的监督者（实习医生或住院医师）提供。这些情况促进了学生的学习动机、团队价值感和对患者的潜在益处。过度信任的特点是任务分配没有明确的指示、监督或反馈。过度信任会引起学生的焦虑和压力，以及对潜在患者伤害的担忧。信任不足的特点是学生角色不明确，导致学生感到沮丧和不满，对患者的影响尚不清楚。学生将不适当的信任归因于背景和监督者因素，由于担心绩效评估和等级制度，他们没有权力进行干预。
结论
作为临床工作场所的早期学习者，学生认为信任需要高水平的支持。对于医学教育工作者来说，重要的是要考虑如何培训住院医师和教师监督者，以不同的方式为学生和住院医师实施信任和监督。鼓励学生和监督者以透明的方式讨论信任和监督的结构可以增强学习。
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