Collaboration for the Advancement of Medical Education Research and Assessment, Faculty of Health, University of Plymouth, Plymouth, UK.
Nuffield Department of Primary Care, Health Sciences, University of Oxford, Oxford, UK.
Med Educ. 2021 Sep;55(9):995-1010. doi: 10.1111/medu.14528. Epub 2021 May 3.
Medical underperformance puts patient safety at risk. Remediation, the process that seeks to 'remedy' underperformance and return a doctor to safe practice, is therefore a crucially important area of medical education. However, although remediation is used in health care systems globally, there is limited evidence for the particular models or strategies employed. The purpose of this study was to conduct a realist review to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety.
We conducted a realist literature review consistent with RAMESES standards. We developed a programme theory of remediation by carrying out a systematic search of the literature and through regular engagement with a stakeholder group. We searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, HMIC, CINAHL, ERIC, ASSIA and DARE) and conducted purposive supplementary searches. Relevant sections of text relating to the programme theory were extracted and synthesised using a realist logic of analysis to identify context-mechanism-outcome configurations (CMOcs).
A 141 records were included. The majority of the studies were from North America (64%). 29 CMOcs were identified. Remediation programmes are effective when a doctor's insight and motivation are developed and behaviour change reinforced. Insight can be developed by providing safe spaces, using advocacy to promote trust and framing feedback sensitively. Motivation can be enhanced by involving the doctor in remediation planning, correcting causal attribution, goal setting and destigmatising remediation. Sustained change can be achieved by practising new behaviours and skills, and through guided reflection.
Remediation can work when it creates environments that trigger behaviour change mechanisms. Our evidence synthesis provides detailed recommendations on tailoring implementation and design strategies to improve remediation interventions for doctors.
医疗表现不佳会危及患者安全。因此，补救措施是医学教育中一个极其重要的领域，它旨在“纠正”表现不佳并使医生恢复安全行医。然而，尽管补救措施在全球医疗保健系统中得到了应用，但针对所采用的特定模式或策略，相关证据有限。本研究旨在进行一项实际主义综述，以确定实践医生的补救计划如何、在何种情况下、针对谁以及在何种程度上能够恢复患者安全。
我们根据 RAMESES 标准进行了实际主义文献综述。我们通过系统地搜索文献并定期与利益相关者群体进行接触，制定了补救方案理论。我们搜索了文献数据库（MEDLINE、EMBASE、PsycINFO、HMIC、CINAHL、ERIC、ASSIA 和 DARE）并进行了有针对性的补充搜索。提取与方案理论相关的文本的相关部分，并使用实际主义分析逻辑对其进行综合分析，以识别情境-机制-结果配置（CMOcs）。
共纳入 141 项记录。大多数研究来自北美（64%）。确定了 29 个 CMOcs。当医生的洞察力和动力得到发展，行为改变得到强化时，补救计划才会有效。可以通过提供安全空间、利用倡导来促进信任以及敏感地构建反馈来发展洞察力。通过让医生参与补救计划制定、纠正因果归因、设定目标和消除补救污名化，可以增强动力。通过练习新的行为和技能以及进行有指导的反思，可以实现持续的改变。
当补救措施创造出触发行为改变机制的环境时，补救措施才会起作用。我们的证据综合提供了详细的建议，即调整实施和设计策略，以改进针对医生的补救干预措施。
